|
ECONAZOLE 1 % TOPICAL CREAM [9915]
|
Facility
IP
|
$4.00
|
|
|
Service Code
|
NDC 51672-1303-1
|
| Hospital Charge Code |
NDG9915
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.96 |
| Max. Negotiated Rate |
$3.40 |
| Rate for Payer: Blue Shield of California Commercial |
$2.85
|
| Rate for Payer: Blue Shield of California EPN |
$2.05
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cigna of CA HMO |
$2.80
|
| Rate for Payer: Cigna of CA PPO |
$2.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.60
|
| Rate for Payer: Galaxy Health WC |
$3.40
|
| Rate for Payer: Global Benefits Group Commercial |
$2.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.96
|
| Rate for Payer: Multiplan Commercial |
$3.20
|
| Rate for Payer: Networks By Design Commercial |
$2.60
|
| Rate for Payer: Prime Health Services Commercial |
$3.40
|
|
|
ECONAZOLE 1 % TOPICAL CREAM [9915]
|
Facility
OP
|
$4.00
|
|
|
Service Code
|
NDC 51672-1303-1
|
| Hospital Charge Code |
NDG9915
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.96 |
| Max. Negotiated Rate |
$3.40 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2.62
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3.40
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.20
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.38
|
| Rate for Payer: BCBS Transplant Transplant |
$2.40
|
| Rate for Payer: Blue Shield of California Commercial |
$2.95
|
| Rate for Payer: Blue Shield of California EPN |
$2.34
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cigna of CA HMO |
$2.80
|
| Rate for Payer: Cigna of CA PPO |
$2.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.40
|
| Rate for Payer: Dignity Health Media |
$3.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.60
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.60
|
| Rate for Payer: Galaxy Health WC |
$3.40
|
| Rate for Payer: Global Benefits Group Commercial |
$2.40
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$3.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.96
|
| Rate for Payer: Multiplan Commercial |
$3.20
|
| Rate for Payer: Networks By Design Commercial |
$2.60
|
| Rate for Payer: Prime Health Services Commercial |
$3.40
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$2.40
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.40
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.40
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.00
|
| Rate for Payer: United Healthcare All Other HMO |
$2.00
|
| Rate for Payer: United Healthcare HMO Rider |
$2.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.40
|
| Rate for Payer: Vantage Medical Group Senior |
$3.40
|
|
|
ECULIZUMAB 300 MG/30 ML INTRAVENOUS SOLUTION [81696]
|
Facility
OP
|
$260.92
|
|
|
Service Code
|
CPT J1300
|
| Hospital Charge Code |
NDG81696
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$62.62 |
| Max. Negotiated Rate |
$1,419.43 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1,419.43
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$282.11
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$248.25
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$248.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$369.42
|
| Rate for Payer: BCBS Transplant Transplant |
$156.55
|
| Rate for Payer: Blue Shield of California Commercial |
$192.30
|
| Rate for Payer: Blue Shield of California EPN |
$260.92
|
| Rate for Payer: Cash Price |
$117.41
|
| Rate for Payer: Cash Price |
$117.41
|
| Rate for Payer: Cigna of CA HMO |
$182.64
|
| Rate for Payer: Cigna of CA PPO |
$182.64
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$338.53
|
| Rate for Payer: Dignity Health Media |
$225.68
|
| Rate for Payer: Dignity Health Medi-Cal |
$248.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$304.67
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$225.68
|
| Rate for Payer: EPIC Health Plan Transplant |
$225.68
|
| Rate for Payer: Galaxy Health WC |
$221.78
|
| Rate for Payer: Global Benefits Group Commercial |
$156.55
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$195.69
|
| Rate for Payer: Heritage Provider Network Commercial |
$370.12
|
| Rate for Payer: Heritage Provider Network Transplant |
$370.12
|
| Rate for Payer: IEHP Medi-Cal |
$365.61
|
| Rate for Payer: IEHP Medi-Cal Transplant |
$365.61
|
| Rate for Payer: IEHP Medicare Advantage |
$225.68
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$174.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$437.28
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$225.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$62.62
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$284.36
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$302.42
|
| Rate for Payer: Multiplan Commercial |
$208.74
|
| Rate for Payer: Networks By Design Commercial |
$130.46
|
| Rate for Payer: Prime Health Services Commercial |
$221.78
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$156.55
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$156.55
|
| Rate for Payer: United Healthcare All Other Commercial |
$130.46
|
| Rate for Payer: United Healthcare All Other HMO |
$130.46
|
| Rate for Payer: United Healthcare HMO Rider |
$130.46
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$130.46
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$338.53
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$248.25
|
| Rate for Payer: Vantage Medical Group Senior |
$225.68
|
|
|
ECULIZUMAB 300 MG/30 ML INTRAVENOUS SOLUTION [81696]
|
Facility
IP
|
$260.92
|
|
|
Service Code
|
CPT J1300
|
| Hospital Charge Code |
NDG81696
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$62.62 |
| Max. Negotiated Rate |
$221.78 |
| Rate for Payer: Blue Shield of California Commercial |
$185.78
|
| Rate for Payer: Blue Shield of California EPN |
$133.59
|
| Rate for Payer: Cash Price |
$117.41
|
| Rate for Payer: Cigna of CA HMO |
$182.64
|
| Rate for Payer: Cigna of CA PPO |
$182.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$104.37
|
| Rate for Payer: EPIC Health Plan Transplant |
$104.37
|
| Rate for Payer: Galaxy Health WC |
$221.78
|
| Rate for Payer: Global Benefits Group Commercial |
$156.55
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$174.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$99.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$62.62
|
| Rate for Payer: Multiplan Commercial |
$208.74
|
| Rate for Payer: Networks By Design Commercial |
$130.46
|
| Rate for Payer: Prime Health Services Commercial |
$221.78
|
|
|
EDETATE CALCIUM DISODIUM 200 MG/ML INJECTION SOLUTION [9916]
|
Facility
IP
|
$1,292.51
|
|
|
Service Code
|
CPT J0600
|
| Hospital Charge Code |
NDG9916
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$310.20 |
| Max. Negotiated Rate |
$1,098.63 |
| Rate for Payer: Blue Shield of California Commercial |
$920.27
|
| Rate for Payer: Blue Shield of California EPN |
$661.77
|
| Rate for Payer: Cash Price |
$581.63
|
| Rate for Payer: Cigna of CA HMO |
$904.76
|
| Rate for Payer: Cigna of CA PPO |
$904.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$517.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$517.00
|
| Rate for Payer: Galaxy Health WC |
$1,098.63
|
| Rate for Payer: Global Benefits Group Commercial |
$775.51
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$862.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$492.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$310.20
|
| Rate for Payer: Multiplan Commercial |
$1,034.01
|
| Rate for Payer: Networks By Design Commercial |
$646.26
|
| Rate for Payer: Prime Health Services Commercial |
$1,098.63
|
|
|
EDETATE CALCIUM DISODIUM 200 MG/ML INJECTION SOLUTION [9916]
|
Facility
OP
|
$1,292.51
|
|
|
Service Code
|
CPT J0600
|
| Hospital Charge Code |
NDG9916
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$75.02 |
| Max. Negotiated Rate |
$40,281.58 |
| Rate for Payer: Aetna of CA HMO/PPO |
$40,281.58
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$8,065.62
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$7,097.75
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$7,097.75
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$75.02
|
| Rate for Payer: BCBS Transplant Transplant |
$775.51
|
| Rate for Payer: Blue Shield of California Commercial |
$952.58
|
| Rate for Payer: Blue Shield of California EPN |
$6,462.56
|
| Rate for Payer: Cash Price |
$581.63
|
| Rate for Payer: Cash Price |
$581.63
|
| Rate for Payer: Cigna of CA HMO |
$904.76
|
| Rate for Payer: Cigna of CA PPO |
$904.76
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9,678.75
|
| Rate for Payer: Dignity Health Media |
$6,452.50
|
| Rate for Payer: Dignity Health Medi-Cal |
$7,097.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$8,710.87
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$6,452.50
|
| Rate for Payer: EPIC Health Plan Transplant |
$6,452.50
|
| Rate for Payer: Galaxy Health WC |
$1,098.63
|
| Rate for Payer: Global Benefits Group Commercial |
$775.51
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$969.38
|
| Rate for Payer: Heritage Provider Network Commercial |
$10,582.10
|
| Rate for Payer: Heritage Provider Network Transplant |
$10,582.10
|
| Rate for Payer: IEHP Medi-Cal |
$10,453.05
|
| Rate for Payer: IEHP Medi-Cal Transplant |
$10,453.05
|
| Rate for Payer: IEHP Medicare Advantage |
$6,452.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$862.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$492.45
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$6,452.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$310.20
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$8,130.15
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$8,646.35
|
| Rate for Payer: Multiplan Commercial |
$1,034.01
|
| Rate for Payer: Networks By Design Commercial |
$646.26
|
| Rate for Payer: Prime Health Services Commercial |
$1,098.63
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$775.51
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$775.51
|
| Rate for Payer: United Healthcare All Other Commercial |
$646.26
|
| Rate for Payer: United Healthcare All Other HMO |
$646.26
|
| Rate for Payer: United Healthcare HMO Rider |
$646.26
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$646.26
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$9,678.75
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7,097.75
|
| Rate for Payer: Vantage Medical Group Senior |
$6,452.50
|
|
|
EDETATE DISODIUM 3 % EYE DROPS [222529]
|
Facility
OP
|
$30.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
NDG222529
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.20 |
| Max. Negotiated Rate |
$25.50 |
| Rate for Payer: Aetna of CA HMO/PPO |
$19.68
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$25.50
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$16.50
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$16.50
|
| Rate for Payer: BCBS Transplant Transplant |
$18.00
|
| Rate for Payer: Blue Shield of California Commercial |
$22.11
|
| Rate for Payer: Blue Shield of California EPN |
$17.52
|
| Rate for Payer: Cash Price |
$13.50
|
| Rate for Payer: Cash Price |
$13.50
|
| Rate for Payer: Cigna of CA HMO |
$21.00
|
| Rate for Payer: Cigna of CA PPO |
$21.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$25.50
|
| Rate for Payer: Dignity Health Media |
$25.50
|
| Rate for Payer: Dignity Health Medi-Cal |
$25.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$12.00
|
| Rate for Payer: Galaxy Health WC |
$25.50
|
| Rate for Payer: Global Benefits Group Commercial |
$18.00
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$22.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$20.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.20
|
| Rate for Payer: Multiplan Commercial |
$24.00
|
| Rate for Payer: Networks By Design Commercial |
$15.00
|
| Rate for Payer: Prime Health Services Commercial |
$25.50
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$18.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$18.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$15.00
|
| Rate for Payer: United Healthcare All Other HMO |
$15.00
|
| Rate for Payer: United Healthcare HMO Rider |
$15.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$15.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$25.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$25.50
|
| Rate for Payer: Vantage Medical Group Senior |
$25.50
|
|
|
EDETATE DISODIUM 3 % EYE DROPS [222529]
|
Facility
IP
|
$30.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
NDG222529
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.20 |
| Max. Negotiated Rate |
$25.50 |
| Rate for Payer: Blue Shield of California Commercial |
$21.36
|
| Rate for Payer: Blue Shield of California EPN |
$15.36
|
| Rate for Payer: Cash Price |
$13.50
|
| Rate for Payer: Cigna of CA HMO |
$21.00
|
| Rate for Payer: Cigna of CA PPO |
$21.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$12.00
|
| Rate for Payer: Galaxy Health WC |
$25.50
|
| Rate for Payer: Global Benefits Group Commercial |
$18.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$20.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$11.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.20
|
| Rate for Payer: Multiplan Commercial |
$24.00
|
| Rate for Payer: Networks By Design Commercial |
$15.00
|
| Rate for Payer: Prime Health Services Commercial |
$25.50
|
|
|
EFAVIRENZ 600 MG TABLET [32298]
|
Facility
OP
|
$3.20
|
|
|
Service Code
|
NDC 31722-504-30
|
| Hospital Charge Code |
1711878
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.77 |
| Max. Negotiated Rate |
$2.72 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2.10
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.72
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.76
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.76
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.91
|
| Rate for Payer: BCBS Transplant Transplant |
$1.92
|
| Rate for Payer: Blue Shield of California Commercial |
$2.36
|
| Rate for Payer: Blue Shield of California EPN |
$1.87
|
| Rate for Payer: Cash Price |
$1.44
|
| Rate for Payer: Cigna of CA HMO |
$2.24
|
| Rate for Payer: Cigna of CA PPO |
$2.24
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.72
|
| Rate for Payer: Dignity Health Media |
$2.72
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.28
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.28
|
| Rate for Payer: Galaxy Health WC |
$2.72
|
| Rate for Payer: Global Benefits Group Commercial |
$1.92
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$2.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.77
|
| Rate for Payer: Multiplan Commercial |
$2.56
|
| Rate for Payer: Networks By Design Commercial |
$2.08
|
| Rate for Payer: Prime Health Services Commercial |
$2.72
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$1.92
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.92
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.92
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.60
|
| Rate for Payer: United Healthcare All Other HMO |
$1.60
|
| Rate for Payer: United Healthcare HMO Rider |
$1.60
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.60
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.72
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.72
|
| Rate for Payer: Vantage Medical Group Senior |
$2.72
|
|
|
EFAVIRENZ 600 MG TABLET [32298]
|
Facility
IP
|
$3.20
|
|
|
Service Code
|
NDC 31722-504-30
|
| Hospital Charge Code |
1711878
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.77 |
| Max. Negotiated Rate |
$2.72 |
| Rate for Payer: Blue Shield of California Commercial |
$2.28
|
| Rate for Payer: Blue Shield of California EPN |
$1.64
|
| Rate for Payer: Cash Price |
$1.44
|
| Rate for Payer: Cigna of CA HMO |
$2.24
|
| Rate for Payer: Cigna of CA PPO |
$2.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.28
|
| Rate for Payer: Galaxy Health WC |
$2.72
|
| Rate for Payer: Global Benefits Group Commercial |
$1.92
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.77
|
| Rate for Payer: Multiplan Commercial |
$2.56
|
| Rate for Payer: Networks By Design Commercial |
$2.08
|
| Rate for Payer: Prime Health Services Commercial |
$2.72
|
|
|
EFLAPEGRASTIM-XNST 13.2 MG/0.6 ML SUBCUTANEOUS SYRINGE [235968]
|
Facility
IP
|
$9,000.00
|
|
|
Service Code
|
CPT J1449
|
| Hospital Charge Code |
NDG235968
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,160.00 |
| Max. Negotiated Rate |
$7,650.00 |
| Rate for Payer: Blue Shield of California Commercial |
$6,408.00
|
| Rate for Payer: Blue Shield of California EPN |
$4,608.00
|
| Rate for Payer: Cash Price |
$4,050.00
|
| Rate for Payer: Cigna of CA HMO |
$6,300.00
|
| Rate for Payer: Cigna of CA PPO |
$6,300.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,600.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$3,600.00
|
| Rate for Payer: Galaxy Health WC |
$7,650.00
|
| Rate for Payer: Global Benefits Group Commercial |
$5,400.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$6,003.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3,429.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,160.00
|
| Rate for Payer: Multiplan Commercial |
$7,200.00
|
| Rate for Payer: Networks By Design Commercial |
$4,500.00
|
| Rate for Payer: Prime Health Services Commercial |
$7,650.00
|
|
|
EFLAPEGRASTIM-XNST 13.2 MG/0.6 ML SUBCUTANEOUS SYRINGE [235968]
|
Facility
OP
|
$9,000.00
|
|
|
Service Code
|
CPT J1449
|
| Hospital Charge Code |
NDG235968
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$29.68 |
| Max. Negotiated Rate |
$7,650.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$186.69
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$37.10
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$32.65
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$32.65
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,362.20
|
| Rate for Payer: BCBS Transplant Transplant |
$5,400.00
|
| Rate for Payer: Blue Shield of California Commercial |
$6,633.00
|
| Rate for Payer: Blue Shield of California EPN |
$5,256.00
|
| Rate for Payer: Cash Price |
$4,050.00
|
| Rate for Payer: Cash Price |
$4,050.00
|
| Rate for Payer: Cigna of CA HMO |
$6,300.00
|
| Rate for Payer: Cigna of CA PPO |
$6,300.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$37.10
|
| Rate for Payer: Dignity Health Media |
$32.65
|
| Rate for Payer: Dignity Health Medi-Cal |
$32.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$40.07
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$29.68
|
| Rate for Payer: EPIC Health Plan Transplant |
$29.68
|
| Rate for Payer: Galaxy Health WC |
$7,650.00
|
| Rate for Payer: Global Benefits Group Commercial |
$5,400.00
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$6,750.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$48.67
|
| Rate for Payer: Heritage Provider Network Transplant |
$48.67
|
| Rate for Payer: IEHP Medi-Cal |
$48.08
|
| Rate for Payer: IEHP Medi-Cal Transplant |
$48.08
|
| Rate for Payer: IEHP Medicare Advantage |
$29.68
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$6,003.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$64.87
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$29.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,160.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$37.40
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$39.77
|
| Rate for Payer: Multiplan Commercial |
$7,200.00
|
| Rate for Payer: Networks By Design Commercial |
$4,500.00
|
| Rate for Payer: Prime Health Services Commercial |
$7,650.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$5,400.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$5,400.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$4,500.00
|
| Rate for Payer: United Healthcare All Other HMO |
$4,500.00
|
| Rate for Payer: United Healthcare HMO Rider |
$4,500.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4,500.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$37.10
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$32.65
|
| Rate for Payer: Vantage Medical Group Senior |
$32.65
|
|
|
ELECTIVE HIP JOINT REPLACEMENT
|
Facility
IP
|
$25,706.30
|
|
|
Service Code
|
APR-DRG 3242
|
| Min. Negotiated Rate |
$19,719.44 |
| Max. Negotiated Rate |
$25,706.30 |
| Rate for Payer: IEHP Medi-Cal |
$19,719.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$25,706.30
|
|
|
ELECTIVE HIP JOINT REPLACEMENT
|
Facility
IP
|
$34,694.19
|
|
|
Service Code
|
APR-DRG 3243
|
| Min. Negotiated Rate |
$26,614.10 |
| Max. Negotiated Rate |
$34,694.19 |
| Rate for Payer: IEHP Medi-Cal |
$26,614.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$34,694.19
|
|
|
ELECTIVE HIP JOINT REPLACEMENT
|
Facility
IP
|
$55,058.85
|
|
|
Service Code
|
APR-DRG 3244
|
| Min. Negotiated Rate |
$42,235.93 |
| Max. Negotiated Rate |
$55,058.85 |
| Rate for Payer: IEHP Medi-Cal |
$42,235.93
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$55,058.85
|
|
|
ELECTIVE HIP JOINT REPLACEMENT
|
Facility
IP
|
$23,594.10
|
|
|
Service Code
|
APR-DRG 3241
|
| Min. Negotiated Rate |
$18,099.16 |
| Max. Negotiated Rate |
$23,594.10 |
| Rate for Payer: IEHP Medi-Cal |
$18,099.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$23,594.10
|
|
|
ELECTIVE KNEE JOINT REPLACEMENT
|
Facility
IP
|
$35,416.00
|
|
|
Service Code
|
APR-DRG 3263
|
| Min. Negotiated Rate |
$27,167.80 |
| Max. Negotiated Rate |
$35,416.00 |
| Rate for Payer: IEHP Medi-Cal |
$27,167.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$35,416.00
|
|
|
ELECTIVE KNEE JOINT REPLACEMENT
|
Facility
IP
|
$23,457.55
|
|
|
Service Code
|
APR-DRG 3261
|
| Min. Negotiated Rate |
$17,994.41 |
| Max. Negotiated Rate |
$23,457.55 |
| Rate for Payer: IEHP Medi-Cal |
$17,994.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$23,457.55
|
|
|
ELECTIVE KNEE JOINT REPLACEMENT
|
Facility
IP
|
$46,409.67
|
|
|
Service Code
|
APR-DRG 3264
|
| Min. Negotiated Rate |
$35,601.10 |
| Max. Negotiated Rate |
$46,409.67 |
| Rate for Payer: IEHP Medi-Cal |
$35,601.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$46,409.67
|
|
|
ELECTIVE KNEE JOINT REPLACEMENT
|
Facility
IP
|
$24,902.92
|
|
|
Service Code
|
APR-DRG 3262
|
| Min. Negotiated Rate |
$19,103.16 |
| Max. Negotiated Rate |
$24,902.92 |
| Rate for Payer: IEHP Medi-Cal |
$19,103.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$24,902.92
|
|
|
ELECTROLYTE-148 INTRAVENOUS SOLUTION [28112]
|
Facility
OP
|
$0.01
|
|
|
Service Code
|
NDC 0338-0179-04
|
| Hospital Charge Code |
1759936
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.01
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.01
|
| Rate for Payer: BCBS Transplant Transplant |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cigna of CA HMO |
$0.01
|
| Rate for Payer: Cigna of CA PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.01
|
| Rate for Payer: Dignity Health Media |
$0.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.00
|
| Rate for Payer: Galaxy Health WC |
$0.01
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: Networks By Design Commercial |
$0.01
|
| Rate for Payer: Prime Health Services Commercial |
$0.01
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.01
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.01
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.01
|
| Rate for Payer: United Healthcare All Other HMO |
$0.01
|
| Rate for Payer: United Healthcare HMO Rider |
$0.01
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Vantage Medical Group Senior |
$0.01
|
|
|
ELECTROLYTE-148 INTRAVENOUS SOLUTION [28112]
|
Facility
IP
|
$0.01
|
|
|
Service Code
|
NDC 0338-0179-04
|
| Hospital Charge Code |
1759936
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.00
|
| Rate for Payer: Galaxy Health WC |
$0.01
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: Networks By Design Commercial |
$0.01
|
| Rate for Payer: Prime Health Services Commercial |
$0.01
|
|
|
ELECTROLYTE-A INTRAVENOUS SOLUTION [28113]
|
Facility
IP
|
$0.02
|
|
|
Service Code
|
NDC 0338-0221-04
|
| Hospital Charge Code |
1771306
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Galaxy Health WC |
$0.02
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: Networks By Design Commercial |
$0.01
|
| Rate for Payer: Prime Health Services Commercial |
$0.02
|
|
|
ELECTROLYTE-A INTRAVENOUS SOLUTION [28113]
|
Facility
OP
|
$0.02
|
|
|
Service Code
|
NDC 0338-0221-04
|
| Hospital Charge Code |
1771306
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.02
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.01
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.01
|
| Rate for Payer: BCBS Transplant Transplant |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO |
$0.01
|
| Rate for Payer: Cigna of CA PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.02
|
| Rate for Payer: Dignity Health Media |
$0.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.01
|
| Rate for Payer: Galaxy Health WC |
$0.02
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: Networks By Design Commercial |
$0.01
|
| Rate for Payer: Prime Health Services Commercial |
$0.02
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.01
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.01
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.01
|
| Rate for Payer: United Healthcare All Other HMO |
$0.01
|
| Rate for Payer: United Healthcare HMO Rider |
$0.01
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.02
|
| Rate for Payer: Vantage Medical Group Senior |
$0.02
|
|
|
ELECTROLYTE-S INTRAVENOUS SOLUTION [28117]
|
Facility
IP
|
$0.01
|
|
|
Service Code
|
NDC 0264-7703-00
|
| Hospital Charge Code |
1771035
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.00
|
| Rate for Payer: Galaxy Health WC |
$0.01
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: Networks By Design Commercial |
$0.01
|
| Rate for Payer: Prime Health Services Commercial |
$0.01
|
|
