|
ESCITALOPRAM 5 MG TABLET [37635]
|
Facility
OP
|
$0.21
|
|
|
Service Code
|
NDC 68180-137-01
|
| Hospital Charge Code |
1712491
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.14
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.18
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.12
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.13
|
| Rate for Payer: BCBS Transplant Transplant |
$0.13
|
| Rate for Payer: Blue Shield of California Commercial |
$0.15
|
| Rate for Payer: Blue Shield of California EPN |
$0.12
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cigna of CA HMO |
$0.15
|
| Rate for Payer: Cigna of CA PPO |
$0.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.18
|
| Rate for Payer: Dignity Health Media |
$0.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.08
|
| Rate for Payer: Galaxy Health WC |
$0.18
|
| Rate for Payer: Global Benefits Group Commercial |
$0.13
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
| Rate for Payer: Networks By Design Commercial |
$0.14
|
| Rate for Payer: Prime Health Services Commercial |
$0.18
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.13
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.13
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.13
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.11
|
| Rate for Payer: United Healthcare All Other HMO |
$0.11
|
| Rate for Payer: United Healthcare HMO Rider |
$0.11
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.11
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.18
|
| Rate for Payer: Vantage Medical Group Senior |
$0.18
|
|
|
ESCITALOPRAM 5 MG TABLET [37635]
|
Facility
OP
|
$0.12
|
|
|
Service Code
|
NDC 68001-454-00
|
| Hospital Charge Code |
1712491
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.10 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.08
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.10
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.07
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.07
|
| Rate for Payer: BCBS Transplant Transplant |
$0.07
|
| Rate for Payer: Blue Shield of California Commercial |
$0.09
|
| Rate for Payer: Blue Shield of California EPN |
$0.07
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO |
$0.08
|
| Rate for Payer: Cigna of CA PPO |
$0.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.10
|
| Rate for Payer: Dignity Health Media |
$0.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.05
|
| Rate for Payer: Galaxy Health WC |
$0.10
|
| Rate for Payer: Global Benefits Group Commercial |
$0.07
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.08
|
| 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 |
$0.10
|
| Rate for Payer: Networks By Design Commercial |
$0.08
|
| Rate for Payer: Prime Health Services Commercial |
$0.10
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.07
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.07
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.07
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.06
|
| Rate for Payer: United Healthcare All Other HMO |
$0.06
|
| Rate for Payer: United Healthcare HMO Rider |
$0.06
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.06
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.10
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.10
|
| Rate for Payer: Vantage Medical Group Senior |
$0.10
|
|
|
ESCITALOPRAM 5 MG TABLET [37635]
|
Facility
OP
|
$0.12
|
|
|
Service Code
|
NDC 16729-168-01
|
| Hospital Charge Code |
1712491
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.10 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.08
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.10
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.07
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.07
|
| Rate for Payer: BCBS Transplant Transplant |
$0.07
|
| Rate for Payer: Blue Shield of California Commercial |
$0.09
|
| Rate for Payer: Blue Shield of California EPN |
$0.07
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO |
$0.08
|
| Rate for Payer: Cigna of CA PPO |
$0.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.10
|
| Rate for Payer: Dignity Health Media |
$0.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.05
|
| Rate for Payer: Galaxy Health WC |
$0.10
|
| Rate for Payer: Global Benefits Group Commercial |
$0.07
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.08
|
| 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 |
$0.10
|
| Rate for Payer: Networks By Design Commercial |
$0.08
|
| Rate for Payer: Prime Health Services Commercial |
$0.10
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.07
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.07
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.07
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.06
|
| Rate for Payer: United Healthcare All Other HMO |
$0.06
|
| Rate for Payer: United Healthcare HMO Rider |
$0.06
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.06
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.10
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.10
|
| Rate for Payer: Vantage Medical Group Senior |
$0.10
|
|
|
ESCITALOPRAM 5 MG TABLET [37635]
|
Facility
IP
|
$0.12
|
|
|
Service Code
|
NDC 43547-280-10
|
| Hospital Charge Code |
1712491
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.10 |
| Rate for Payer: Blue Shield of California Commercial |
$0.09
|
| Rate for Payer: Blue Shield of California EPN |
$0.06
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO |
$0.08
|
| Rate for Payer: Cigna of CA PPO |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: Galaxy Health WC |
$0.10
|
| Rate for Payer: Global Benefits Group Commercial |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.08
|
| 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 |
$0.10
|
| Rate for Payer: Networks By Design Commercial |
$0.08
|
| Rate for Payer: Prime Health Services Commercial |
$0.10
|
|
|
ESLICARBAZEPINE 200 MG TABLET [204958]
|
Facility
IP
|
$47.95
|
|
|
Service Code
|
NDC 63402-202-30
|
| Hospital Charge Code |
ERX204958
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$11.51 |
| Max. Negotiated Rate |
$40.76 |
| Rate for Payer: Blue Shield of California Commercial |
$34.14
|
| Rate for Payer: Blue Shield of California EPN |
$24.55
|
| Rate for Payer: Cash Price |
$21.58
|
| Rate for Payer: Cigna of CA HMO |
$33.56
|
| Rate for Payer: Cigna of CA PPO |
$33.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$19.18
|
| Rate for Payer: Galaxy Health WC |
$40.76
|
| Rate for Payer: Global Benefits Group Commercial |
$28.77
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$31.98
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$18.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.51
|
| Rate for Payer: Multiplan Commercial |
$38.36
|
| Rate for Payer: Networks By Design Commercial |
$31.17
|
| Rate for Payer: Prime Health Services Commercial |
$40.76
|
|
|
ESLICARBAZEPINE 200 MG TABLET [204958]
|
Facility
OP
|
$47.95
|
|
|
Service Code
|
NDC 63402-202-30
|
| Hospital Charge Code |
ERX204958
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$11.51 |
| Max. Negotiated Rate |
$40.76 |
| Rate for Payer: Aetna of CA HMO/PPO |
$31.45
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$40.76
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$26.37
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$26.37
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$28.57
|
| Rate for Payer: BCBS Transplant Transplant |
$28.77
|
| Rate for Payer: Blue Shield of California Commercial |
$35.34
|
| Rate for Payer: Blue Shield of California EPN |
$28.00
|
| Rate for Payer: Cash Price |
$21.58
|
| Rate for Payer: Cigna of CA HMO |
$33.56
|
| Rate for Payer: Cigna of CA PPO |
$33.56
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$40.76
|
| Rate for Payer: Dignity Health Media |
$40.76
|
| Rate for Payer: Dignity Health Medi-Cal |
$40.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$19.18
|
| Rate for Payer: EPIC Health Plan Transplant |
$19.18
|
| Rate for Payer: Galaxy Health WC |
$40.76
|
| Rate for Payer: Global Benefits Group Commercial |
$28.77
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$35.96
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$31.98
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$18.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.51
|
| Rate for Payer: Multiplan Commercial |
$38.36
|
| Rate for Payer: Networks By Design Commercial |
$31.17
|
| Rate for Payer: Prime Health Services Commercial |
$40.76
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$28.77
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$28.77
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$28.77
|
| Rate for Payer: United Healthcare All Other Commercial |
$23.98
|
| Rate for Payer: United Healthcare All Other HMO |
$23.98
|
| Rate for Payer: United Healthcare HMO Rider |
$23.98
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$23.98
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$40.76
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$40.76
|
| Rate for Payer: Vantage Medical Group Senior |
$40.76
|
|
|
ESLICARBAZEPINE 400 MG TABLET [204960]
|
Facility
IP
|
$47.95
|
|
|
Service Code
|
NDC 63402-204-30
|
| Hospital Charge Code |
ERX204960
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$11.51 |
| Max. Negotiated Rate |
$40.76 |
| Rate for Payer: Blue Shield of California Commercial |
$34.14
|
| Rate for Payer: Blue Shield of California EPN |
$24.55
|
| Rate for Payer: Cash Price |
$21.58
|
| Rate for Payer: Cigna of CA HMO |
$33.56
|
| Rate for Payer: Cigna of CA PPO |
$33.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$19.18
|
| Rate for Payer: Galaxy Health WC |
$40.76
|
| Rate for Payer: Global Benefits Group Commercial |
$28.77
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$31.98
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$18.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.51
|
| Rate for Payer: Multiplan Commercial |
$38.36
|
| Rate for Payer: Networks By Design Commercial |
$31.17
|
| Rate for Payer: Prime Health Services Commercial |
$40.76
|
|
|
ESLICARBAZEPINE 400 MG TABLET [204960]
|
Facility
OP
|
$47.95
|
|
|
Service Code
|
NDC 63402-204-30
|
| Hospital Charge Code |
ERX204960
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$11.51 |
| Max. Negotiated Rate |
$40.76 |
| Rate for Payer: Aetna of CA HMO/PPO |
$31.45
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$40.76
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$26.37
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$26.37
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$28.57
|
| Rate for Payer: BCBS Transplant Transplant |
$28.77
|
| Rate for Payer: Blue Shield of California Commercial |
$35.34
|
| Rate for Payer: Blue Shield of California EPN |
$28.00
|
| Rate for Payer: Cash Price |
$21.58
|
| Rate for Payer: Cigna of CA HMO |
$33.56
|
| Rate for Payer: Cigna of CA PPO |
$33.56
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$40.76
|
| Rate for Payer: Dignity Health Media |
$40.76
|
| Rate for Payer: Dignity Health Medi-Cal |
$40.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$19.18
|
| Rate for Payer: EPIC Health Plan Transplant |
$19.18
|
| Rate for Payer: Galaxy Health WC |
$40.76
|
| Rate for Payer: Global Benefits Group Commercial |
$28.77
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$35.96
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$31.98
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$18.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.51
|
| Rate for Payer: Multiplan Commercial |
$38.36
|
| Rate for Payer: Networks By Design Commercial |
$31.17
|
| Rate for Payer: Prime Health Services Commercial |
$40.76
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$28.77
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$28.77
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$28.77
|
| Rate for Payer: United Healthcare All Other Commercial |
$23.98
|
| Rate for Payer: United Healthcare All Other HMO |
$23.98
|
| Rate for Payer: United Healthcare HMO Rider |
$23.98
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$23.98
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$40.76
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$40.76
|
| Rate for Payer: Vantage Medical Group Senior |
$40.76
|
|
|
ESLICARBAZEPINE 600 MG TABLET [204961]
|
Facility
OP
|
$47.95
|
|
|
Service Code
|
NDC 63402-206-60
|
| Hospital Charge Code |
ERX204961
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$11.51 |
| Max. Negotiated Rate |
$40.76 |
| Rate for Payer: Aetna of CA HMO/PPO |
$31.45
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$40.76
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$26.37
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$26.37
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$28.57
|
| Rate for Payer: BCBS Transplant Transplant |
$28.77
|
| Rate for Payer: Blue Shield of California Commercial |
$35.34
|
| Rate for Payer: Blue Shield of California EPN |
$28.00
|
| Rate for Payer: Cash Price |
$21.58
|
| Rate for Payer: Cigna of CA HMO |
$33.56
|
| Rate for Payer: Cigna of CA PPO |
$33.56
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$40.76
|
| Rate for Payer: Dignity Health Media |
$40.76
|
| Rate for Payer: Dignity Health Medi-Cal |
$40.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$19.18
|
| Rate for Payer: EPIC Health Plan Transplant |
$19.18
|
| Rate for Payer: Galaxy Health WC |
$40.76
|
| Rate for Payer: Global Benefits Group Commercial |
$28.77
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$35.96
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$31.98
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$18.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.51
|
| Rate for Payer: Multiplan Commercial |
$38.36
|
| Rate for Payer: Networks By Design Commercial |
$31.17
|
| Rate for Payer: Prime Health Services Commercial |
$40.76
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$28.77
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$28.77
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$28.77
|
| Rate for Payer: United Healthcare All Other Commercial |
$23.98
|
| Rate for Payer: United Healthcare All Other HMO |
$23.98
|
| Rate for Payer: United Healthcare HMO Rider |
$23.98
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$23.98
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$40.76
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$40.76
|
| Rate for Payer: Vantage Medical Group Senior |
$40.76
|
|
|
ESLICARBAZEPINE 600 MG TABLET [204961]
|
Facility
IP
|
$47.95
|
|
|
Service Code
|
NDC 63402-206-60
|
| Hospital Charge Code |
ERX204961
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$11.51 |
| Max. Negotiated Rate |
$40.76 |
| Rate for Payer: Blue Shield of California Commercial |
$34.14
|
| Rate for Payer: Blue Shield of California EPN |
$24.55
|
| Rate for Payer: Cash Price |
$21.58
|
| Rate for Payer: Cigna of CA HMO |
$33.56
|
| Rate for Payer: Cigna of CA PPO |
$33.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$19.18
|
| Rate for Payer: Galaxy Health WC |
$40.76
|
| Rate for Payer: Global Benefits Group Commercial |
$28.77
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$31.98
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$18.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.51
|
| Rate for Payer: Multiplan Commercial |
$38.36
|
| Rate for Payer: Networks By Design Commercial |
$31.17
|
| Rate for Payer: Prime Health Services Commercial |
$40.76
|
|
|
ESLICARBAZEPINE 800 MG TABLET [204959]
|
Facility
IP
|
$47.95
|
|
|
Service Code
|
NDC 63402-208-30
|
| Hospital Charge Code |
ERX204959
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$11.51 |
| Max. Negotiated Rate |
$40.76 |
| Rate for Payer: Blue Shield of California Commercial |
$34.14
|
| Rate for Payer: Blue Shield of California EPN |
$24.55
|
| Rate for Payer: Cash Price |
$21.58
|
| Rate for Payer: Cigna of CA HMO |
$33.56
|
| Rate for Payer: Cigna of CA PPO |
$33.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$19.18
|
| Rate for Payer: Galaxy Health WC |
$40.76
|
| Rate for Payer: Global Benefits Group Commercial |
$28.77
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$31.98
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$18.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.51
|
| Rate for Payer: Multiplan Commercial |
$38.36
|
| Rate for Payer: Networks By Design Commercial |
$31.17
|
| Rate for Payer: Prime Health Services Commercial |
$40.76
|
|
|
ESLICARBAZEPINE 800 MG TABLET [204959]
|
Facility
OP
|
$47.95
|
|
|
Service Code
|
NDC 63402-208-30
|
| Hospital Charge Code |
ERX204959
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$11.51 |
| Max. Negotiated Rate |
$40.76 |
| Rate for Payer: Aetna of CA HMO/PPO |
$31.45
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$40.76
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$26.37
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$26.37
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$28.57
|
| Rate for Payer: BCBS Transplant Transplant |
$28.77
|
| Rate for Payer: Blue Shield of California Commercial |
$35.34
|
| Rate for Payer: Blue Shield of California EPN |
$28.00
|
| Rate for Payer: Cash Price |
$21.58
|
| Rate for Payer: Cigna of CA HMO |
$33.56
|
| Rate for Payer: Cigna of CA PPO |
$33.56
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$40.76
|
| Rate for Payer: Dignity Health Media |
$40.76
|
| Rate for Payer: Dignity Health Medi-Cal |
$40.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$19.18
|
| Rate for Payer: EPIC Health Plan Transplant |
$19.18
|
| Rate for Payer: Galaxy Health WC |
$40.76
|
| Rate for Payer: Global Benefits Group Commercial |
$28.77
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$35.96
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$31.98
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$18.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.51
|
| Rate for Payer: Multiplan Commercial |
$38.36
|
| Rate for Payer: Networks By Design Commercial |
$31.17
|
| Rate for Payer: Prime Health Services Commercial |
$40.76
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$28.77
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$28.77
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$28.77
|
| Rate for Payer: United Healthcare All Other Commercial |
$23.98
|
| Rate for Payer: United Healthcare All Other HMO |
$23.98
|
| Rate for Payer: United Healthcare HMO Rider |
$23.98
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$23.98
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$40.76
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$40.76
|
| Rate for Payer: Vantage Medical Group Senior |
$40.76
|
|
|
ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION [9957]
|
Facility
OP
|
$0.53
|
|
|
Service Code
|
CPT J1805
|
| Hospital Charge Code |
1720612
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$8.97 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.62
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.62
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.33
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.33
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.29
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.29
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.29
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.29
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.32
|
| Rate for Payer: BCBS Transplant Transplant |
$0.32
|
| Rate for Payer: BCBS Transplant Transplant |
$0.50
|
| Rate for Payer: Blue Shield of California Commercial |
$0.62
|
| Rate for Payer: Blue Shield of California Commercial |
$0.39
|
| Rate for Payer: Blue Shield of California EPN |
$0.49
|
| Rate for Payer: Blue Shield of California EPN |
$0.31
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: Cash Price |
$0.38
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: Cash Price |
$0.38
|
| Rate for Payer: Cigna of CA HMO |
$0.59
|
| Rate for Payer: Cigna of CA HMO |
$0.37
|
| Rate for Payer: Cigna of CA PPO |
$0.59
|
| Rate for Payer: Cigna of CA PPO |
$0.37
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.39
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.39
|
| Rate for Payer: Dignity Health Media |
$0.26
|
| Rate for Payer: Dignity Health Media |
$0.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.29
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.35
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$0.26
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$0.26
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.26
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.26
|
| Rate for Payer: Galaxy Health WC |
$0.71
|
| Rate for Payer: Galaxy Health WC |
$0.45
|
| Rate for Payer: Global Benefits Group Commercial |
$0.50
|
| Rate for Payer: Global Benefits Group Commercial |
$0.32
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.63
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.43
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.43
|
| Rate for Payer: Heritage Provider Network Transplant |
$0.43
|
| Rate for Payer: Heritage Provider Network Transplant |
$0.43
|
| Rate for Payer: IEHP Medi-Cal |
$0.42
|
| Rate for Payer: IEHP Medi-Cal |
$0.42
|
| Rate for Payer: IEHP Medi-Cal Transplant |
$0.42
|
| Rate for Payer: IEHP Medi-Cal Transplant |
$0.42
|
| Rate for Payer: IEHP Medicare Advantage |
$0.26
|
| Rate for Payer: IEHP Medicare Advantage |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.35
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.97
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.33
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.33
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.35
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.35
|
| Rate for Payer: Multiplan Commercial |
$0.42
|
| Rate for Payer: Multiplan Commercial |
$0.67
|
| Rate for Payer: Networks By Design Commercial |
$0.42
|
| Rate for Payer: Networks By Design Commercial |
$0.27
|
| Rate for Payer: Prime Health Services Commercial |
$0.45
|
| Rate for Payer: Prime Health Services Commercial |
$0.71
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.50
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.32
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.32
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.50
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.27
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.42
|
| Rate for Payer: United Healthcare All Other HMO |
$0.27
|
| Rate for Payer: United Healthcare All Other HMO |
$0.42
|
| Rate for Payer: United Healthcare HMO Rider |
$0.27
|
| Rate for Payer: United Healthcare HMO Rider |
$0.42
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.27
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.42
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.39
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.39
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.29
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.29
|
| Rate for Payer: Vantage Medical Group Senior |
$0.26
|
| Rate for Payer: Vantage Medical Group Senior |
$0.26
|
|
|
ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION [9957]
|
Facility
IP
|
$0.53
|
|
|
Service Code
|
CPT J1805
|
| Hospital Charge Code |
1720612
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.45 |
| Rate for Payer: Blue Shield of California Commercial |
$0.38
|
| Rate for Payer: Blue Shield of California Commercial |
$0.60
|
| Rate for Payer: Blue Shield of California EPN |
$0.27
|
| Rate for Payer: Blue Shield of California EPN |
$0.43
|
| Rate for Payer: Cash Price |
$0.38
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: Cigna of CA HMO |
$0.59
|
| Rate for Payer: Cigna of CA HMO |
$0.37
|
| Rate for Payer: Cigna of CA PPO |
$0.59
|
| Rate for Payer: Cigna of CA PPO |
$0.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.21
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.21
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.34
|
| Rate for Payer: Galaxy Health WC |
$0.71
|
| Rate for Payer: Galaxy Health WC |
$0.45
|
| Rate for Payer: Global Benefits Group Commercial |
$0.50
|
| Rate for Payer: Global Benefits Group Commercial |
$0.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.56
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.32
|
| 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 |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.42
|
| Rate for Payer: Multiplan Commercial |
$0.67
|
| Rate for Payer: Networks By Design Commercial |
$0.42
|
| Rate for Payer: Networks By Design Commercial |
$0.27
|
| Rate for Payer: Prime Health Services Commercial |
$0.45
|
| Rate for Payer: Prime Health Services Commercial |
$0.71
|
|
|
ESMOLOL 2,000 MG/100 ML (20 MG/ML) IN SODIUM CHLORIDE (ISO-OSMOTIC) IV [35639]
|
Facility
OP
|
$6.05
|
|
|
Service Code
|
CPT J1805
|
| Hospital Charge Code |
1759130
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$8.97 |
| Rate for Payer: BCBS Transplant Transplant |
$1.08
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.62
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.62
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.62
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.33
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.33
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.33
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.29
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.29
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.29
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.29
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.29
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.29
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.07
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.60
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.14
|
| Rate for Payer: BCBS Transplant Transplant |
$3.63
|
| Rate for Payer: BCBS Transplant Transplant |
$1.15
|
| Rate for Payer: Blue Shield of California Commercial |
$4.46
|
| Rate for Payer: Blue Shield of California Commercial |
$1.33
|
| Rate for Payer: Blue Shield of California Commercial |
$1.42
|
| Rate for Payer: Blue Shield of California EPN |
$1.05
|
| Rate for Payer: Blue Shield of California EPN |
$3.53
|
| Rate for Payer: Blue Shield of California EPN |
$1.12
|
| Rate for Payer: Cash Price |
$0.81
|
| Rate for Payer: Cash Price |
$2.72
|
| Rate for Payer: Cash Price |
$0.81
|
| Rate for Payer: Cash Price |
$0.86
|
| Rate for Payer: Cash Price |
$2.72
|
| Rate for Payer: Cash Price |
$0.86
|
| Rate for Payer: Cigna of CA HMO |
$4.24
|
| Rate for Payer: Cigna of CA HMO |
$1.26
|
| Rate for Payer: Cigna of CA HMO |
$1.34
|
| Rate for Payer: Cigna of CA PPO |
$4.24
|
| Rate for Payer: Cigna of CA PPO |
$1.26
|
| Rate for Payer: Cigna of CA PPO |
$1.34
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.39
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.39
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.39
|
| Rate for Payer: Dignity Health Media |
$0.26
|
| Rate for Payer: Dignity Health Media |
$0.26
|
| Rate for Payer: Dignity Health Media |
$0.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.29
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.29
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.35
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$0.26
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$0.26
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$0.26
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.26
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.26
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.26
|
| Rate for Payer: Galaxy Health WC |
$5.14
|
| Rate for Payer: Galaxy Health WC |
$1.63
|
| Rate for Payer: Galaxy Health WC |
$1.53
|
| Rate for Payer: Global Benefits Group Commercial |
$3.63
|
| Rate for Payer: Global Benefits Group Commercial |
$1.08
|
| Rate for Payer: Global Benefits Group Commercial |
$1.15
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1.35
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$4.54
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1.44
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.43
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.43
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.43
|
| Rate for Payer: Heritage Provider Network Transplant |
$0.43
|
| Rate for Payer: Heritage Provider Network Transplant |
$0.43
|
| Rate for Payer: Heritage Provider Network Transplant |
$0.43
|
| Rate for Payer: IEHP Medi-Cal |
$0.42
|
| Rate for Payer: IEHP Medi-Cal |
$0.42
|
| Rate for Payer: IEHP Medi-Cal |
$0.42
|
| Rate for Payer: IEHP Medi-Cal Transplant |
$0.42
|
| Rate for Payer: IEHP Medi-Cal Transplant |
$0.42
|
| Rate for Payer: IEHP Medi-Cal Transplant |
$0.42
|
| Rate for Payer: IEHP Medicare Advantage |
$0.26
|
| Rate for Payer: IEHP Medicare Advantage |
$0.26
|
| Rate for Payer: IEHP Medicare Advantage |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.97
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.45
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.33
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.33
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.33
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.35
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.35
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.35
|
| Rate for Payer: Multiplan Commercial |
$4.84
|
| Rate for Payer: Multiplan Commercial |
$1.44
|
| Rate for Payer: Multiplan Commercial |
$1.54
|
| Rate for Payer: Networks By Design Commercial |
$3.02
|
| Rate for Payer: Networks By Design Commercial |
$0.96
|
| Rate for Payer: Networks By Design Commercial |
$0.90
|
| Rate for Payer: Prime Health Services Commercial |
$1.63
|
| Rate for Payer: Prime Health Services Commercial |
$5.14
|
| Rate for Payer: Prime Health Services Commercial |
$1.53
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.63
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.08
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.15
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.15
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.63
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.08
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.90
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.96
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.02
|
| Rate for Payer: United Healthcare All Other HMO |
$3.02
|
| Rate for Payer: United Healthcare All Other HMO |
$0.96
|
| Rate for Payer: United Healthcare All Other HMO |
$0.90
|
| Rate for Payer: United Healthcare HMO Rider |
$3.02
|
| Rate for Payer: United Healthcare HMO Rider |
$0.90
|
| Rate for Payer: United Healthcare HMO Rider |
$0.96
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.02
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.96
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.90
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.39
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.39
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.39
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.29
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.29
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.29
|
| Rate for Payer: Vantage Medical Group Senior |
$0.26
|
| Rate for Payer: Vantage Medical Group Senior |
$0.26
|
| Rate for Payer: Vantage Medical Group Senior |
$0.26
|
|
|
ESMOLOL 2,000 MG/100 ML (20 MG/ML) IN SODIUM CHLORIDE (ISO-OSMOTIC) IV [35639]
|
Facility
IP
|
$1.92
|
|
|
Service Code
|
CPT J1805
|
| Hospital Charge Code |
1759130
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.46 |
| Max. Negotiated Rate |
$1.63 |
| Rate for Payer: Blue Shield of California Commercial |
$1.37
|
| Rate for Payer: Blue Shield of California Commercial |
$1.28
|
| Rate for Payer: Blue Shield of California Commercial |
$4.31
|
| Rate for Payer: Blue Shield of California EPN |
$3.10
|
| Rate for Payer: Blue Shield of California EPN |
$0.98
|
| Rate for Payer: Blue Shield of California EPN |
$0.92
|
| Rate for Payer: Cash Price |
$0.81
|
| Rate for Payer: Cash Price |
$0.86
|
| Rate for Payer: Cash Price |
$2.72
|
| Rate for Payer: Cigna of CA HMO |
$1.34
|
| Rate for Payer: Cigna of CA HMO |
$4.24
|
| Rate for Payer: Cigna of CA HMO |
$1.26
|
| Rate for Payer: Cigna of CA PPO |
$1.26
|
| Rate for Payer: Cigna of CA PPO |
$1.34
|
| Rate for Payer: Cigna of CA PPO |
$4.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.42
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.42
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.72
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.77
|
| Rate for Payer: Galaxy Health WC |
$5.14
|
| Rate for Payer: Galaxy Health WC |
$1.53
|
| Rate for Payer: Galaxy Health WC |
$1.63
|
| Rate for Payer: Global Benefits Group Commercial |
$1.08
|
| Rate for Payer: Global Benefits Group Commercial |
$1.15
|
| Rate for Payer: Global Benefits Group Commercial |
$3.63
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.28
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.69
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.43
|
| Rate for Payer: Multiplan Commercial |
$1.54
|
| Rate for Payer: Multiplan Commercial |
$1.44
|
| Rate for Payer: Multiplan Commercial |
$4.84
|
| Rate for Payer: Networks By Design Commercial |
$0.96
|
| Rate for Payer: Networks By Design Commercial |
$0.90
|
| Rate for Payer: Networks By Design Commercial |
$3.02
|
| Rate for Payer: Prime Health Services Commercial |
$1.53
|
| Rate for Payer: Prime Health Services Commercial |
$5.14
|
| Rate for Payer: Prime Health Services Commercial |
$1.63
|
|
|
ESMOLOL 2,000 MG/100 ML (20 MG/ML) IN STERILE WATER INTRAVENOUS SOLN [221109]
|
Facility
IP
|
$1.55
|
|
|
Service Code
|
CPT J1806
|
| Hospital Charge Code |
NDG221109
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.37 |
| Max. Negotiated Rate |
$1.32 |
| Rate for Payer: Blue Shield of California Commercial |
$1.10
|
| Rate for Payer: Blue Shield of California EPN |
$0.79
|
| Rate for Payer: Cash Price |
$0.70
|
| Rate for Payer: Cigna of CA HMO |
$1.08
|
| Rate for Payer: Cigna of CA PPO |
$1.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.62
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.62
|
| Rate for Payer: Galaxy Health WC |
$1.32
|
| Rate for Payer: Global Benefits Group Commercial |
$0.93
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.37
|
| Rate for Payer: Multiplan Commercial |
$1.24
|
| Rate for Payer: Networks By Design Commercial |
$0.78
|
| Rate for Payer: Prime Health Services Commercial |
$1.32
|
|
|
ESMOLOL 2,000 MG/100 ML (20 MG/ML) IN STERILE WATER INTRAVENOUS SOLN [221109]
|
Facility
OP
|
$1.55
|
|
|
Service Code
|
CPT J1806
|
| Hospital Charge Code |
NDG221109
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.37 |
| Max. Negotiated Rate |
$9.33 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2.86
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.57
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.50
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.92
|
| Rate for Payer: BCBS Transplant Transplant |
$0.93
|
| Rate for Payer: Blue Shield of California Commercial |
$1.14
|
| Rate for Payer: Blue Shield of California EPN |
$0.91
|
| Rate for Payer: Cash Price |
$0.70
|
| Rate for Payer: Cash Price |
$0.70
|
| Rate for Payer: Cigna of CA HMO |
$1.08
|
| Rate for Payer: Cigna of CA PPO |
$1.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.68
|
| Rate for Payer: Dignity Health Media |
$0.45
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.61
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$0.45
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.45
|
| Rate for Payer: Galaxy Health WC |
$1.32
|
| Rate for Payer: Global Benefits Group Commercial |
$0.93
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.74
|
| Rate for Payer: Heritage Provider Network Transplant |
$0.74
|
| Rate for Payer: IEHP Medi-Cal |
$0.73
|
| Rate for Payer: IEHP Medi-Cal Transplant |
$0.73
|
| Rate for Payer: IEHP Medicare Advantage |
$0.45
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9.33
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.37
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.57
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.61
|
| Rate for Payer: Multiplan Commercial |
$1.24
|
| Rate for Payer: Networks By Design Commercial |
$0.78
|
| Rate for Payer: Prime Health Services Commercial |
$1.32
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.93
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.93
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.78
|
| Rate for Payer: United Healthcare All Other HMO |
$0.78
|
| Rate for Payer: United Healthcare HMO Rider |
$0.78
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.78
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.68
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.50
|
| Rate for Payer: Vantage Medical Group Senior |
$0.45
|
|
|
ESMOLOL 2,500 MG/250 ML (10 MG/ML) IN SODIUM CHLORIDE (ISO-OSMOTIC) IV [29805]
|
Facility
IP
|
$2.25
|
|
|
Service Code
|
CPT J1805
|
| Hospital Charge Code |
1759131
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.54 |
| Max. Negotiated Rate |
$1.91 |
| Rate for Payer: Blue Shield of California Commercial |
$1.60
|
| Rate for Payer: Blue Shield of California Commercial |
$0.56
|
| Rate for Payer: Blue Shield of California Commercial |
$1.10
|
| Rate for Payer: Blue Shield of California EPN |
$0.40
|
| Rate for Payer: Blue Shield of California EPN |
$0.79
|
| Rate for Payer: Blue Shield of California EPN |
$1.15
|
| Rate for Payer: Cash Price |
$1.01
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Cash Price |
$0.70
|
| Rate for Payer: Cigna of CA HMO |
$0.55
|
| Rate for Payer: Cigna of CA HMO |
$1.08
|
| Rate for Payer: Cigna of CA HMO |
$1.58
|
| Rate for Payer: Cigna of CA PPO |
$0.55
|
| Rate for Payer: Cigna of CA PPO |
$1.08
|
| Rate for Payer: Cigna of CA PPO |
$1.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.62
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.90
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.62
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.32
|
| Rate for Payer: Galaxy Health WC |
$0.67
|
| Rate for Payer: Galaxy Health WC |
$1.91
|
| Rate for Payer: Galaxy Health WC |
$1.32
|
| Rate for Payer: Global Benefits Group Commercial |
$1.35
|
| Rate for Payer: Global Benefits Group Commercial |
$0.47
|
| Rate for Payer: Global Benefits Group Commercial |
$0.93
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.53
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: Multiplan Commercial |
$0.63
|
| Rate for Payer: Multiplan Commercial |
$1.80
|
| Rate for Payer: Multiplan Commercial |
$1.24
|
| Rate for Payer: Networks By Design Commercial |
$0.40
|
| Rate for Payer: Networks By Design Commercial |
$0.78
|
| Rate for Payer: Networks By Design Commercial |
$1.12
|
| Rate for Payer: Prime Health Services Commercial |
$1.91
|
| Rate for Payer: Prime Health Services Commercial |
$0.67
|
| Rate for Payer: Prime Health Services Commercial |
$1.32
|
|
|
ESMOLOL 2,500 MG/250 ML (10 MG/ML) IN SODIUM CHLORIDE (ISO-OSMOTIC) IV [29805]
|
Facility
OP
|
$1.55
|
|
|
Service Code
|
CPT J1805
|
| Hospital Charge Code |
1759131
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$8.97 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.62
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.62
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.62
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.33
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.33
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.33
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.29
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.29
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.29
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.29
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.29
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.29
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.92
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.34
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.47
|
| Rate for Payer: BCBS Transplant Transplant |
$0.93
|
| Rate for Payer: BCBS Transplant Transplant |
$0.47
|
| Rate for Payer: BCBS Transplant Transplant |
$1.35
|
| Rate for Payer: Blue Shield of California Commercial |
$1.14
|
| Rate for Payer: Blue Shield of California Commercial |
$1.66
|
| Rate for Payer: Blue Shield of California Commercial |
$0.58
|
| Rate for Payer: Blue Shield of California EPN |
$0.91
|
| Rate for Payer: Blue Shield of California EPN |
$0.46
|
| Rate for Payer: Blue Shield of California EPN |
$1.31
|
| Rate for Payer: Cash Price |
$0.70
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Cash Price |
$1.01
|
| Rate for Payer: Cash Price |
$1.01
|
| Rate for Payer: Cash Price |
$0.70
|
| Rate for Payer: Cigna of CA HMO |
$1.08
|
| Rate for Payer: Cigna of CA HMO |
$0.55
|
| Rate for Payer: Cigna of CA HMO |
$1.58
|
| Rate for Payer: Cigna of CA PPO |
$1.58
|
| Rate for Payer: Cigna of CA PPO |
$0.55
|
| Rate for Payer: Cigna of CA PPO |
$1.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.39
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.39
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.39
|
| Rate for Payer: Dignity Health Media |
$0.26
|
| Rate for Payer: Dignity Health Media |
$0.26
|
| Rate for Payer: Dignity Health Media |
$0.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.29
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.29
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.35
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$0.26
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$0.26
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$0.26
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.26
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.26
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.26
|
| Rate for Payer: Galaxy Health WC |
$1.91
|
| Rate for Payer: Galaxy Health WC |
$1.32
|
| Rate for Payer: Galaxy Health WC |
$0.67
|
| Rate for Payer: Global Benefits Group Commercial |
$0.93
|
| Rate for Payer: Global Benefits Group Commercial |
$1.35
|
| Rate for Payer: Global Benefits Group Commercial |
$0.47
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1.69
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1.16
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.59
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.43
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.43
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.43
|
| Rate for Payer: Heritage Provider Network Transplant |
$0.43
|
| Rate for Payer: Heritage Provider Network Transplant |
$0.43
|
| Rate for Payer: Heritage Provider Network Transplant |
$0.43
|
| Rate for Payer: IEHP Medi-Cal |
$0.42
|
| Rate for Payer: IEHP Medi-Cal |
$0.42
|
| Rate for Payer: IEHP Medi-Cal |
$0.42
|
| Rate for Payer: IEHP Medi-Cal Transplant |
$0.42
|
| Rate for Payer: IEHP Medi-Cal Transplant |
$0.42
|
| Rate for Payer: IEHP Medi-Cal Transplant |
$0.42
|
| Rate for Payer: IEHP Medicare Advantage |
$0.26
|
| Rate for Payer: IEHP Medicare Advantage |
$0.26
|
| Rate for Payer: IEHP Medicare Advantage |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.53
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.97
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.37
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.33
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.33
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.33
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.35
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.35
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.35
|
| Rate for Payer: Multiplan Commercial |
$0.63
|
| Rate for Payer: Multiplan Commercial |
$1.80
|
| Rate for Payer: Multiplan Commercial |
$1.24
|
| Rate for Payer: Networks By Design Commercial |
$0.40
|
| Rate for Payer: Networks By Design Commercial |
$0.78
|
| Rate for Payer: Networks By Design Commercial |
$1.12
|
| Rate for Payer: Prime Health Services Commercial |
$1.91
|
| Rate for Payer: Prime Health Services Commercial |
$0.67
|
| Rate for Payer: Prime Health Services Commercial |
$1.32
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.93
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.47
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.35
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.47
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.35
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.93
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.78
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.40
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.12
|
| Rate for Payer: United Healthcare All Other HMO |
$0.78
|
| Rate for Payer: United Healthcare All Other HMO |
$1.12
|
| Rate for Payer: United Healthcare All Other HMO |
$0.40
|
| Rate for Payer: United Healthcare HMO Rider |
$0.40
|
| Rate for Payer: United Healthcare HMO Rider |
$0.78
|
| Rate for Payer: United Healthcare HMO Rider |
$1.12
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.78
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.40
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.12
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.39
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.39
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.39
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.29
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.29
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.29
|
| Rate for Payer: Vantage Medical Group Senior |
$0.26
|
| Rate for Payer: Vantage Medical Group Senior |
$0.26
|
| Rate for Payer: Vantage Medical Group Senior |
$0.26
|
|
|
ESOMEPRAZOLE MAGNESIUM 20 MG CAPSULE,DELAYED RELEASE [29745]
|
Facility
IP
|
$11.01
|
|
|
Service Code
|
NDC 0186-5020-54
|
| Hospital Charge Code |
1711865
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.64 |
| Max. Negotiated Rate |
$9.36 |
| Rate for Payer: Blue Shield of California Commercial |
$7.84
|
| Rate for Payer: Blue Shield of California EPN |
$5.64
|
| Rate for Payer: Cash Price |
$4.95
|
| Rate for Payer: Cigna of CA HMO |
$7.71
|
| Rate for Payer: Cigna of CA PPO |
$7.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.40
|
| Rate for Payer: Galaxy Health WC |
$9.36
|
| Rate for Payer: Global Benefits Group Commercial |
$6.61
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$7.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.64
|
| Rate for Payer: Multiplan Commercial |
$8.81
|
| Rate for Payer: Networks By Design Commercial |
$7.16
|
| Rate for Payer: Prime Health Services Commercial |
$9.36
|
|
|
ESOMEPRAZOLE MAGNESIUM 20 MG CAPSULE,DELAYED RELEASE [29745]
|
Facility
OP
|
$11.01
|
|
|
Service Code
|
NDC 0186-5020-54
|
| Hospital Charge Code |
1711865
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.64 |
| Max. Negotiated Rate |
$9.36 |
| Rate for Payer: Aetna of CA HMO/PPO |
$7.22
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$9.36
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$6.06
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$6.06
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6.56
|
| Rate for Payer: BCBS Transplant Transplant |
$6.61
|
| Rate for Payer: Blue Shield of California Commercial |
$8.11
|
| Rate for Payer: Blue Shield of California EPN |
$6.43
|
| Rate for Payer: Cash Price |
$4.95
|
| Rate for Payer: Cigna of CA HMO |
$7.71
|
| Rate for Payer: Cigna of CA PPO |
$7.71
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.36
|
| Rate for Payer: Dignity Health Media |
$9.36
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.40
|
| Rate for Payer: EPIC Health Plan Transplant |
$4.40
|
| Rate for Payer: Galaxy Health WC |
$9.36
|
| Rate for Payer: Global Benefits Group Commercial |
$6.61
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$8.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$7.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.64
|
| Rate for Payer: Multiplan Commercial |
$8.81
|
| Rate for Payer: Networks By Design Commercial |
$7.16
|
| Rate for Payer: Prime Health Services Commercial |
$9.36
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$6.61
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$6.61
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$6.61
|
| Rate for Payer: United Healthcare All Other Commercial |
$5.50
|
| Rate for Payer: United Healthcare All Other HMO |
$5.50
|
| Rate for Payer: United Healthcare HMO Rider |
$5.50
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$5.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$9.36
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.36
|
| Rate for Payer: Vantage Medical Group Senior |
$9.36
|
|
|
ESOMEPRAZOLE MAGNESIUM 40 MG CAPSULE,DELAYED RELEASE [29746]
|
Facility
OP
|
$11.01
|
|
|
Service Code
|
NDC 0186-5040-54
|
| Hospital Charge Code |
1711866
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.64 |
| Max. Negotiated Rate |
$9.36 |
| Rate for Payer: Aetna of CA HMO/PPO |
$7.22
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$9.36
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$6.06
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$6.06
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6.56
|
| Rate for Payer: BCBS Transplant Transplant |
$6.61
|
| Rate for Payer: Blue Shield of California Commercial |
$8.11
|
| Rate for Payer: Blue Shield of California EPN |
$6.43
|
| Rate for Payer: Cash Price |
$4.95
|
| Rate for Payer: Cigna of CA HMO |
$7.71
|
| Rate for Payer: Cigna of CA PPO |
$7.71
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.36
|
| Rate for Payer: Dignity Health Media |
$9.36
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.40
|
| Rate for Payer: EPIC Health Plan Transplant |
$4.40
|
| Rate for Payer: Galaxy Health WC |
$9.36
|
| Rate for Payer: Global Benefits Group Commercial |
$6.61
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$8.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$7.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.64
|
| Rate for Payer: Multiplan Commercial |
$8.81
|
| Rate for Payer: Networks By Design Commercial |
$7.16
|
| Rate for Payer: Prime Health Services Commercial |
$9.36
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$6.61
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$6.61
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$6.61
|
| Rate for Payer: United Healthcare All Other Commercial |
$5.50
|
| Rate for Payer: United Healthcare All Other HMO |
$5.50
|
| Rate for Payer: United Healthcare HMO Rider |
$5.50
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$5.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$9.36
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.36
|
| Rate for Payer: Vantage Medical Group Senior |
$9.36
|
|
|
ESOMEPRAZOLE MAGNESIUM 40 MG CAPSULE,DELAYED RELEASE [29746]
|
Facility
IP
|
$11.01
|
|
|
Service Code
|
NDC 0186-5040-54
|
| Hospital Charge Code |
1711866
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.64 |
| Max. Negotiated Rate |
$9.36 |
| Rate for Payer: Blue Shield of California Commercial |
$7.84
|
| Rate for Payer: Blue Shield of California EPN |
$5.64
|
| Rate for Payer: Cash Price |
$4.95
|
| Rate for Payer: Cigna of CA HMO |
$7.71
|
| Rate for Payer: Cigna of CA PPO |
$7.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.40
|
| Rate for Payer: Galaxy Health WC |
$9.36
|
| Rate for Payer: Global Benefits Group Commercial |
$6.61
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$7.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.64
|
| Rate for Payer: Multiplan Commercial |
$8.81
|
| Rate for Payer: Networks By Design Commercial |
$7.16
|
| Rate for Payer: Prime Health Services Commercial |
$9.36
|
|
|
ESOMEPRAZOLE MAGNESIUM DR 10 MG GRANULES DELAYED RELEASE FOR SUSP [91031]
|
Facility
OP
|
$11.49
|
|
|
Service Code
|
NDC 0186-4010-01
|
| Hospital Charge Code |
ERX91031
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.76 |
| Max. Negotiated Rate |
$9.77 |
| Rate for Payer: Aetna of CA HMO/PPO |
$7.54
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$9.77
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$6.32
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$6.32
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6.85
|
| Rate for Payer: BCBS Transplant Transplant |
$6.89
|
| Rate for Payer: Blue Shield of California Commercial |
$8.47
|
| Rate for Payer: Blue Shield of California EPN |
$6.71
|
| Rate for Payer: Cash Price |
$5.17
|
| Rate for Payer: Cigna of CA HMO |
$8.04
|
| Rate for Payer: Cigna of CA PPO |
$8.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.77
|
| Rate for Payer: Dignity Health Media |
$9.77
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.60
|
| Rate for Payer: EPIC Health Plan Transplant |
$4.60
|
| Rate for Payer: Galaxy Health WC |
$9.77
|
| Rate for Payer: Global Benefits Group Commercial |
$6.89
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$8.62
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$7.66
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.76
|
| Rate for Payer: Multiplan Commercial |
$9.19
|
| Rate for Payer: Networks By Design Commercial |
$7.47
|
| Rate for Payer: Prime Health Services Commercial |
$9.77
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$6.89
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$6.89
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$6.89
|
| Rate for Payer: United Healthcare All Other Commercial |
$5.74
|
| Rate for Payer: United Healthcare All Other HMO |
$5.74
|
| Rate for Payer: United Healthcare HMO Rider |
$5.74
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$5.74
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$9.77
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.77
|
| Rate for Payer: Vantage Medical Group Senior |
$9.77
|
|
