|
FAMOTIDINE 40 MG/5 ML (8 MG/ML) ORAL SUSPENSION [10010]
|
Facility
|
OP
|
$2.38
|
|
|
Service Code
|
NDC 68180-150-01
|
| Hospital Charge Code |
1715188
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$2.02 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.56
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.02
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.31
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.31
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.42
|
| Rate for Payer: Blue Distinction Transplant |
$1.43
|
| Rate for Payer: Blue Shield of California Commercial |
$1.75
|
| Rate for Payer: Blue Shield of California EPN |
$1.39
|
| Rate for Payer: Cash Price |
$1.07
|
| Rate for Payer: Cigna of CA HMO |
$1.67
|
| Rate for Payer: Cigna of CA PPO |
$1.67
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.02
|
| Rate for Payer: Dignity Health Media |
$2.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.95
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.95
|
| Rate for Payer: Galaxy Health WC |
$2.02
|
| Rate for Payer: Global Benefits Group Commercial |
$1.43
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$1.78
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.57
|
| Rate for Payer: Multiplan Commercial |
$1.90
|
| Rate for Payer: Networks By Design Commercial |
$1.55
|
| Rate for Payer: Prime Health Services Commercial |
$2.02
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.43
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.43
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.19
|
| Rate for Payer: United Healthcare All Other HMO |
$1.19
|
| Rate for Payer: United Healthcare HMO Rider |
$1.19
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.19
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.02
|
| Rate for Payer: Vantage Medical Group Senior |
$2.02
|
|
|
FAMOTIDINE 40 MG/5 ML (8 MG/ML) ORAL SUSPENSION [10010]
|
Facility
|
IP
|
$2.38
|
|
|
Service Code
|
NDC 68180-150-01
|
| Hospital Charge Code |
1715188
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$2.02 |
| Rate for Payer: Blue Shield of California Commercial |
$1.69
|
| Rate for Payer: Blue Shield of California EPN |
$1.22
|
| Rate for Payer: Cash Price |
$1.07
|
| Rate for Payer: Cigna of CA HMO |
$1.67
|
| Rate for Payer: Cigna of CA PPO |
$1.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.95
|
| Rate for Payer: Galaxy Health WC |
$2.02
|
| Rate for Payer: Global Benefits Group Commercial |
$1.43
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.57
|
| Rate for Payer: Multiplan Commercial |
$1.90
|
| Rate for Payer: Networks By Design Commercial |
$1.55
|
| Rate for Payer: Prime Health Services Commercial |
$2.02
|
|
|
FAMOTIDINE 40 MG/5 ML (8 MG/ML) ORAL SUSPENSION [10010]
|
Facility
|
IP
|
$2.37
|
|
|
Service Code
|
NDC 68382-444-05
|
| Hospital Charge Code |
1715188
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$2.01 |
| Rate for Payer: Blue Shield of California Commercial |
$1.69
|
| Rate for Payer: Blue Shield of California EPN |
$1.21
|
| Rate for Payer: Cash Price |
$1.07
|
| Rate for Payer: Cigna of CA HMO |
$1.66
|
| Rate for Payer: Cigna of CA PPO |
$1.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.95
|
| Rate for Payer: Galaxy Health WC |
$2.01
|
| Rate for Payer: Global Benefits Group Commercial |
$1.42
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.57
|
| Rate for Payer: Multiplan Commercial |
$1.90
|
| Rate for Payer: Networks By Design Commercial |
$1.54
|
| Rate for Payer: Prime Health Services Commercial |
$2.01
|
|
|
FAMOTIDINE 40 MG/5 ML (8 MG/ML) ORAL SUSPENSION [10010]
|
Facility
|
OP
|
$2.37
|
|
|
Service Code
|
NDC 68382-444-05
|
| Hospital Charge Code |
1715188
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$2.01 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.55
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.01
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.30
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.30
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.41
|
| Rate for Payer: Blue Distinction Transplant |
$1.42
|
| Rate for Payer: Blue Shield of California Commercial |
$1.75
|
| Rate for Payer: Blue Shield of California EPN |
$1.38
|
| Rate for Payer: Cash Price |
$1.07
|
| Rate for Payer: Cigna of CA HMO |
$1.66
|
| Rate for Payer: Cigna of CA PPO |
$1.66
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.01
|
| Rate for Payer: Dignity Health Media |
$2.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.95
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.95
|
| Rate for Payer: Galaxy Health WC |
$2.01
|
| Rate for Payer: Global Benefits Group Commercial |
$1.42
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$1.78
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.57
|
| Rate for Payer: Multiplan Commercial |
$1.90
|
| Rate for Payer: Networks By Design Commercial |
$1.54
|
| Rate for Payer: Prime Health Services Commercial |
$2.01
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.42
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.42
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.18
|
| Rate for Payer: United Healthcare All Other HMO |
$1.18
|
| Rate for Payer: United Healthcare HMO Rider |
$1.18
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.18
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.01
|
| Rate for Payer: Vantage Medical Group Senior |
$2.01
|
|
|
FAMOTIDINE 40 MG TABLET [10012]
|
Facility
|
IP
|
$0.35
|
|
|
Service Code
|
NDC 50268-304-11
|
| Hospital Charge Code |
1712055
|
|
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
|
|
|
FAMOTIDINE 40 MG TABLET [10012]
|
Facility
|
OP
|
$0.48
|
|
|
Service Code
|
NDC 62332-002-31
|
| Hospital Charge Code |
1712055
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.41 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.31
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.41
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.26
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.26
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.29
|
| Rate for Payer: Blue Distinction Transplant |
$0.29
|
| Rate for Payer: Blue Shield of California Commercial |
$0.35
|
| Rate for Payer: Blue Shield of California EPN |
$0.28
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Cigna of CA HMO |
$0.34
|
| Rate for Payer: Cigna of CA PPO |
$0.34
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.41
|
| Rate for Payer: Dignity Health Media |
$0.41
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.19
|
| Rate for Payer: Galaxy Health WC |
$0.41
|
| Rate for Payer: Global Benefits Group Commercial |
$0.29
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.36
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.38
|
| Rate for Payer: Networks By Design Commercial |
$0.31
|
| Rate for Payer: Prime Health Services Commercial |
$0.41
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.29
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.29
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.24
|
| Rate for Payer: United Healthcare All Other HMO |
$0.24
|
| Rate for Payer: United Healthcare HMO Rider |
$0.24
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.24
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.41
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.41
|
| Rate for Payer: Vantage Medical Group Senior |
$0.41
|
|
|
FAMOTIDINE 40 MG TABLET [10012]
|
Facility
|
OP
|
$0.34
|
|
|
Service Code
|
NDC 0172-5729-60
|
| Hospital Charge Code |
1712055
|
|
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
|
|
|
FAMOTIDINE 40 MG TABLET [10012]
|
Facility
|
OP
|
$0.35
|
|
|
Service Code
|
NDC 50268-304-15
|
| Hospital Charge Code |
1712055
|
|
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
|
|
|
FAMOTIDINE 40 MG TABLET [10012]
|
Facility
|
IP
|
$0.35
|
|
|
Service Code
|
NDC 50268-304-15
|
| Hospital Charge Code |
1712055
|
|
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
|
|
|
FAMOTIDINE 40 MG TABLET [10012]
|
Facility
|
OP
|
$0.35
|
|
|
Service Code
|
NDC 50268-304-11
|
| Hospital Charge Code |
1712055
|
|
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
|
|
|
FAMOTIDINE 40 MG TABLET [10012]
|
Facility
|
IP
|
$0.34
|
|
|
Service Code
|
NDC 0172-5729-60
|
| Hospital Charge Code |
1712055
|
|
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
|
|
|
FAMOTIDINE 40 MG TABLET [10012]
|
Facility
|
OP
|
$0.34
|
|
|
Service Code
|
NDC 68001-398-00
|
| Hospital Charge Code |
1712055
|
|
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
|
|
|
FAMOTIDINE 40 MG TABLET [10012]
|
Facility
|
IP
|
$0.34
|
|
|
Service Code
|
NDC 68001-398-00
|
| Hospital Charge Code |
1712055
|
|
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
|
|
|
FAMOTIDINE 40 MG TABLET [10012]
|
Facility
|
IP
|
$0.48
|
|
|
Service Code
|
NDC 62332-002-31
|
| Hospital Charge Code |
1712055
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.41 |
| Rate for Payer: Blue Shield of California Commercial |
$0.34
|
| Rate for Payer: Blue Shield of California EPN |
$0.25
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Cigna of CA HMO |
$0.34
|
| Rate for Payer: Cigna of CA PPO |
$0.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| Rate for Payer: Galaxy Health WC |
$0.41
|
| Rate for Payer: Global Benefits Group Commercial |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.38
|
| Rate for Payer: Networks By Design Commercial |
$0.31
|
| Rate for Payer: Prime Health Services Commercial |
$0.41
|
|
|
FAMOTIDINE IN STERILE WATER 2 MG/ML SPECIAL CONCENTRATION [204598]
|
Facility
|
IP
|
$0.14
|
|
|
Service Code
|
CPT S0028
|
| Hospital Charge Code |
1754204
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Blue Shield of California Commercial |
$0.10
|
| Rate for Payer: Blue Shield of California EPN |
$0.07
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA HMO |
$0.10
|
| Rate for Payer: Cigna of CA PPO |
$0.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.06
|
| Rate for Payer: Galaxy Health WC |
$0.12
|
| Rate for Payer: Global Benefits Group Commercial |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
| Rate for Payer: Networks By Design Commercial |
$0.07
|
| Rate for Payer: Prime Health Services Commercial |
$0.12
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.05
|
| Rate for Payer: United Healthcare All Other HMO |
$0.05
|
| Rate for Payer: United Healthcare HMO Rider |
$0.05
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.05
|
|
|
FAMOTIDINE IN STERILE WATER 2 MG/ML SPECIAL CONCENTRATION [204598]
|
Facility
|
OP
|
$0.14
|
|
|
Service Code
|
CPT S0028
|
| Hospital Charge Code |
1754204
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$5.60 |
| Rate for Payer: Aetna of CA HMO/PPO |
$5.60
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.08
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.08
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.97
|
| Rate for Payer: Blue Distinction Transplant |
$0.08
|
| Rate for Payer: Blue Shield of California Commercial |
$0.10
|
| Rate for Payer: Blue Shield of California EPN |
$1.07
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA HMO |
$0.10
|
| Rate for Payer: Cigna of CA PPO |
$0.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.12
|
| Rate for Payer: Dignity Health Media |
$0.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.06
|
| Rate for Payer: Galaxy Health WC |
$0.12
|
| Rate for Payer: Global Benefits Group Commercial |
$0.08
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
| Rate for Payer: Networks By Design Commercial |
$0.07
|
| Rate for Payer: Prime Health Services Commercial |
$0.12
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.08
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.08
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.07
|
| Rate for Payer: United Healthcare All Other HMO |
$0.07
|
| Rate for Payer: United Healthcare HMO Rider |
$0.07
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.07
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: Vantage Medical Group Senior |
$0.12
|
|
|
FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION [119375]
|
Facility
|
IP
|
$0.52
|
|
|
Service Code
|
CPT S0028
|
| Hospital Charge Code |
1768064
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.44 |
| Rate for Payer: Blue Shield of California Commercial |
$0.37
|
| Rate for Payer: Blue Shield of California Commercial |
$0.38
|
| Rate for Payer: Blue Shield of California Commercial |
$0.38
|
| Rate for Payer: Blue Shield of California EPN |
$0.27
|
| Rate for Payer: Blue Shield of California EPN |
$0.28
|
| Rate for Payer: Blue Shield of California EPN |
$0.27
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: Cigna of CA HMO |
$0.38
|
| Rate for Payer: Cigna of CA HMO |
$0.37
|
| Rate for Payer: Cigna of CA HMO |
$0.36
|
| Rate for Payer: Cigna of CA PPO |
$0.36
|
| Rate for Payer: Cigna of CA PPO |
$0.37
|
| Rate for Payer: Cigna of CA PPO |
$0.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.22
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.22
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.21
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.21
|
| Rate for Payer: Galaxy Health WC |
$0.45
|
| Rate for Payer: Galaxy Health WC |
$0.44
|
| Rate for Payer: Galaxy Health WC |
$0.46
|
| Rate for Payer: Global Benefits Group Commercial |
$0.32
|
| Rate for Payer: Global Benefits Group Commercial |
$0.31
|
| Rate for Payer: Global Benefits Group Commercial |
$0.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.35
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.35
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.20
|
| 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: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.42
|
| Rate for Payer: Multiplan Commercial |
$0.42
|
| Rate for Payer: Multiplan Commercial |
$0.43
|
| Rate for Payer: Networks By Design Commercial |
$0.27
|
| Rate for Payer: Networks By Design Commercial |
$0.26
|
| Rate for Payer: Networks By Design Commercial |
$0.27
|
| Rate for Payer: Prime Health Services Commercial |
$0.44
|
| Rate for Payer: Prime Health Services Commercial |
$0.45
|
| Rate for Payer: Prime Health Services Commercial |
$0.46
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.20
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.20
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.20
|
| Rate for Payer: United Healthcare All Other HMO |
$0.20
|
| Rate for Payer: United Healthcare All Other HMO |
$0.19
|
| Rate for Payer: United Healthcare All Other HMO |
$0.20
|
| Rate for Payer: United Healthcare HMO Rider |
$0.19
|
| Rate for Payer: United Healthcare HMO Rider |
$0.19
|
| Rate for Payer: United Healthcare HMO Rider |
$0.19
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.17
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.17
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.18
|
|
|
FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION [119375]
|
Facility
|
OP
|
$0.53
|
|
|
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: Aetna of CA HMO/PPO |
$5.60
|
| Rate for Payer: Aetna of CA HMO/PPO |
$5.60
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.45
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.46
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.44
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.30
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.29
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.29
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.30
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.29
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.29
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.97
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.97
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.97
|
| Rate for Payer: Blue Distinction Transplant |
$0.32
|
| Rate for Payer: Blue Distinction Transplant |
$0.31
|
| Rate for Payer: Blue Distinction Transplant |
$0.32
|
| Rate for Payer: Blue Shield of California Commercial |
$0.39
|
| Rate for Payer: Blue Shield of California Commercial |
$0.38
|
| Rate for Payer: Blue Shield of California Commercial |
$0.40
|
| Rate for Payer: Blue Shield of California EPN |
$1.07
|
| Rate for Payer: Blue Shield of California EPN |
$1.07
|
| 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: Cash Price |
$0.24
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Cigna of CA HMO |
$0.38
|
| Rate for Payer: Cigna of CA HMO |
$0.37
|
| Rate for Payer: Cigna of CA HMO |
$0.36
|
| Rate for Payer: Cigna of CA PPO |
$0.38
|
| Rate for Payer: Cigna of CA PPO |
$0.37
|
| Rate for Payer: Cigna of CA PPO |
$0.36
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.45
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.46
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.44
|
| Rate for Payer: Dignity Health Media |
$0.44
|
| Rate for Payer: Dignity Health Media |
$0.45
|
| Rate for Payer: Dignity Health Media |
$0.46
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.44
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.46
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.22
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.21
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.21
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.22
|
| Rate for Payer: Galaxy Health WC |
$0.46
|
| Rate for Payer: Galaxy Health WC |
$0.45
|
| Rate for Payer: Galaxy Health WC |
$0.44
|
| Rate for Payer: Global Benefits Group Commercial |
$0.32
|
| Rate for Payer: Global Benefits Group Commercial |
$0.32
|
| Rate for Payer: Global Benefits Group Commercial |
$0.31
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.41
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.40
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.39
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.35
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.35
|
| 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: Kaiser Permanente of CA Medi-Cal |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.43
|
| Rate for Payer: Multiplan Commercial |
$0.42
|
| Rate for Payer: Multiplan Commercial |
$0.42
|
| Rate for Payer: Networks By Design Commercial |
$0.27
|
| Rate for Payer: Networks By Design Commercial |
$0.26
|
| Rate for Payer: Networks By Design Commercial |
$0.27
|
| Rate for Payer: Prime Health Services Commercial |
$0.44
|
| Rate for Payer: Prime Health Services Commercial |
$0.46
|
| Rate for Payer: Prime Health Services Commercial |
$0.45
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.32
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.32
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.31
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.32
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.32
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.31
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.27
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.27
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.26
|
| Rate for Payer: United Healthcare All Other HMO |
$0.27
|
| Rate for Payer: United Healthcare All Other HMO |
$0.27
|
| Rate for Payer: United Healthcare All Other HMO |
$0.26
|
| Rate for Payer: United Healthcare HMO Rider |
$0.26
|
| Rate for Payer: United Healthcare HMO Rider |
$0.27
|
| Rate for Payer: United Healthcare HMO Rider |
$0.27
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.27
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.26
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.27
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.44
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.45
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.46
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.45
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.46
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.44
|
| Rate for Payer: Vantage Medical Group Senior |
$0.46
|
| Rate for Payer: Vantage Medical Group Senior |
$0.44
|
| Rate for Payer: Vantage Medical Group Senior |
$0.45
|
|
|
FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG INTRAVENOUS SOLUTION [226729]
|
Facility
|
OP
|
$3,178.67
|
|
|
Service Code
|
NDC 65597-406-01
|
| Hospital Charge Code |
ERX226729
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$762.88 |
| Max. Negotiated Rate |
$2,701.87 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2,084.89
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2,701.87
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,748.27
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,748.27
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,893.85
|
| Rate for Payer: Blue Distinction Transplant |
$1,907.20
|
| Rate for Payer: Blue Shield of California Commercial |
$2,342.68
|
| Rate for Payer: Blue Shield of California EPN |
$1,856.34
|
| Rate for Payer: Cash Price |
$1,430.40
|
| Rate for Payer: Cigna of CA HMO |
$2,225.07
|
| Rate for Payer: Cigna of CA PPO |
$2,225.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2,701.87
|
| Rate for Payer: Dignity Health Media |
$2,701.87
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,701.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,271.47
|
| Rate for Payer: EPIC Health Plan Transplant |
$1,271.47
|
| Rate for Payer: Galaxy Health WC |
$2,701.87
|
| Rate for Payer: Global Benefits Group Commercial |
$1,907.20
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$2,384.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2,120.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,211.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$762.88
|
| Rate for Payer: Multiplan Commercial |
$2,542.94
|
| Rate for Payer: Networks By Design Commercial |
$1,589.34
|
| Rate for Payer: Prime Health Services Commercial |
$2,701.87
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1,907.20
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1,907.20
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,589.34
|
| Rate for Payer: United Healthcare All Other HMO |
$1,589.34
|
| Rate for Payer: United Healthcare HMO Rider |
$1,589.34
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,589.34
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2,701.87
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,701.87
|
| Rate for Payer: Vantage Medical Group Senior |
$2,701.87
|
|
|
FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG INTRAVENOUS SOLUTION [226729]
|
Facility
|
IP
|
$3,178.67
|
|
|
Service Code
|
NDC 65597-406-01
|
| Hospital Charge Code |
ERX226729
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$762.88 |
| Max. Negotiated Rate |
$2,701.87 |
| Rate for Payer: Blue Shield of California Commercial |
$2,263.21
|
| Rate for Payer: Blue Shield of California EPN |
$1,627.48
|
| Rate for Payer: Cash Price |
$1,430.40
|
| Rate for Payer: Cigna of CA HMO |
$2,225.07
|
| Rate for Payer: Cigna of CA PPO |
$2,225.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,271.47
|
| Rate for Payer: EPIC Health Plan Transplant |
$1,271.47
|
| Rate for Payer: Galaxy Health WC |
$2,701.87
|
| Rate for Payer: Global Benefits Group Commercial |
$1,907.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2,120.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,211.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$762.88
|
| Rate for Payer: Multiplan Commercial |
$2,542.94
|
| Rate for Payer: Networks By Design Commercial |
$1,589.34
|
| Rate for Payer: Prime Health Services Commercial |
$2,701.87
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,200.27
|
| Rate for Payer: United Healthcare All Other HMO |
$1,172.29
|
| Rate for Payer: United Healthcare HMO Rider |
$1,146.86
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,048.96
|
|
|
FAT EMULSION 20 % INTRAVENOUS [10014]
|
Facility
|
IP
|
$0.09
|
|
|
Service Code
|
NDC 0338-0519-14
|
| Hospital Charge Code |
1767008
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Blue Shield of California Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.08
|
| Rate for Payer: Global Benefits Group Commercial |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.07
|
| Rate for Payer: Networks By Design Commercial |
$0.06
|
| Rate for Payer: Prime Health Services Commercial |
$0.08
|
|
|
FAT EMULSION 20 % INTRAVENOUS [10014]
|
Facility
|
IP
|
$0.05
|
|
|
Service Code
|
NDC 0264-4460-00
|
| Hospital Charge Code |
1767008
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Blue Shield of California Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California EPN |
$0.03
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.04
|
| Rate for Payer: Global Benefits Group Commercial |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.04
|
| Rate for Payer: Networks By Design Commercial |
$0.03
|
| Rate for Payer: Prime Health Services Commercial |
$0.04
|
|
|
FAT EMULSION 20 % INTRAVENOUS [10014]
|
Facility
|
OP
|
$0.09
|
|
|
Service Code
|
NDC 0338-0519-14
|
| Hospital Charge Code |
1767008
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.08
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.05
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.05
|
| Rate for Payer: Blue Distinction Transplant |
$0.05
|
| Rate for Payer: Blue Shield of California Commercial |
$0.07
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO |
$0.06
|
| Rate for Payer: Cigna of CA PPO |
$0.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.08
|
| Rate for Payer: Dignity Health Media |
$0.08
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.08
|
| Rate for Payer: Global Benefits Group Commercial |
$0.05
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.07
|
| Rate for Payer: Networks By Design Commercial |
$0.06
|
| Rate for Payer: Prime Health Services Commercial |
$0.08
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.05
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.05
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.05
|
| Rate for Payer: United Healthcare All Other HMO |
$0.05
|
| Rate for Payer: United Healthcare HMO Rider |
$0.05
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.05
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.08
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.08
|
| Rate for Payer: Vantage Medical Group Senior |
$0.08
|
|
|
FAT EMULSION 20 % INTRAVENOUS [10014]
|
Facility
|
OP
|
$0.05
|
|
|
Service Code
|
NDC 0264-4460-00
|
| Hospital Charge Code |
1767008
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.03
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.03
|
| Rate for Payer: Blue Distinction Transplant |
$0.03
|
| Rate for Payer: Blue Shield of California Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California EPN |
$0.03
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of CA HMO |
$0.03
|
| Rate for Payer: Cigna of CA PPO |
$0.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.04
|
| Rate for Payer: Dignity Health Media |
$0.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.04
|
| Rate for Payer: Global Benefits Group Commercial |
$0.03
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.04
|
| Rate for Payer: Networks By Design Commercial |
$0.03
|
| Rate for Payer: Prime Health Services Commercial |
$0.04
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.03
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.03
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.03
|
| Rate for Payer: United Healthcare All Other HMO |
$0.03
|
| Rate for Payer: United Healthcare HMO Rider |
$0.03
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.03
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: Vantage Medical Group Senior |
$0.04
|
|
|
FAT EMULSION 20 % IV RATE BASED [40840048]
|
Facility
|
OP
|
$0.24
|
|
|
Service Code
|
NDC L4084-048-15
|
| Hospital Charge Code |
ERX40840048
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.16
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.13
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.13
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.14
|
| Rate for Payer: Blue Distinction Transplant |
$0.14
|
| Rate for Payer: Blue Shield of California Commercial |
$0.18
|
| Rate for Payer: Blue Shield of California EPN |
$0.14
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cigna of CA HMO |
$0.15
|
| Rate for Payer: Cigna of CA PPO |
$0.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.20
|
| Rate for Payer: Dignity Health Media |
$0.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.10
|
| Rate for Payer: Galaxy Health WC |
$0.20
|
| Rate for Payer: Global Benefits Group Commercial |
$0.14
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.18
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.19
|
| Rate for Payer: Networks By Design Commercial |
$0.16
|
| Rate for Payer: Prime Health Services Commercial |
$0.20
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.14
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.14
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.12
|
| Rate for Payer: United Healthcare All Other HMO |
$0.12
|
| Rate for Payer: United Healthcare HMO Rider |
$0.12
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.12
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.20
|
| Rate for Payer: Vantage Medical Group Senior |
$0.20
|
|
