|
B-COMPLEX WITH VITAMIN C TABLET [807]
|
Facility
|
OP
|
$0.08
|
|
|
Service Code
|
NDC 3160401338
|
| Hospital Charge Code |
1711835
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.05
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.04
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.05
|
| Rate for Payer: Blue Distinction Transplant |
$0.05
|
| Rate for Payer: Blue Shield of California Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO |
$0.06
|
| Rate for Payer: Cigna of CA PPO |
$0.06
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.07
|
| Rate for Payer: Dignity Health Media |
$0.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.03
|
| Rate for Payer: Galaxy Health WC |
$0.07
|
| Rate for Payer: Global Benefits Group Commercial |
$0.05
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
| Rate for Payer: Networks By Design Commercial |
$0.05
|
| Rate for Payer: Prime Health Services Commercial |
$0.07
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.05
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.05
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.04
|
| Rate for Payer: United Healthcare All Other HMO |
$0.04
|
| Rate for Payer: United Healthcare HMO Rider |
$0.04
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: Vantage Medical Group Senior |
$0.07
|
|
|
B-COMPLEX WITH VITAMIN C TABLET [807]
|
Facility
|
OP
|
$0.03
|
|
|
Service Code
|
NDC 8068112600
|
| Hospital Charge Code |
1711835
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.02
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.02
|
| Rate for Payer: Blue Distinction Transplant |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO |
$0.02
|
| Rate for Payer: Cigna of CA PPO |
$0.02
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.03
|
| Rate for Payer: Dignity Health Media |
$0.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.01
|
| Rate for Payer: Galaxy Health WC |
$0.03
|
| Rate for Payer: Global Benefits Group Commercial |
$0.02
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: Networks By Design Commercial |
$0.02
|
| Rate for Payer: Prime Health Services Commercial |
$0.03
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.02
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.02
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.02
|
| Rate for Payer: United Healthcare All Other HMO |
$0.02
|
| Rate for Payer: United Healthcare HMO Rider |
$0.02
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Vantage Medical Group Senior |
$0.03
|
|
|
B-COMPLEX WITH VITAMIN C TABLET [807]
|
Facility
|
IP
|
$0.03
|
|
|
Service Code
|
NDC 8068112600
|
| Hospital Charge Code |
1711835
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Blue Shield of California Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO |
$0.02
|
| Rate for Payer: Cigna of CA PPO |
$0.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Galaxy Health WC |
$0.03
|
| Rate for Payer: Global Benefits Group Commercial |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: Networks By Design Commercial |
$0.02
|
| Rate for Payer: Prime Health Services Commercial |
$0.03
|
|
|
B-COMPLEX WITH VITAMIN C TABLET [807]
|
Facility
|
IP
|
$0.08
|
|
|
Service Code
|
NDC 3160401338
|
| Hospital Charge Code |
1711835
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Blue Shield of California Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.04
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO |
$0.06
|
| Rate for Payer: Cigna of CA PPO |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: Galaxy Health WC |
$0.07
|
| Rate for Payer: Global Benefits Group Commercial |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
| Rate for Payer: Networks By Design Commercial |
$0.05
|
| Rate for Payer: Prime Health Services Commercial |
$0.07
|
|
|
B-COMPLEX WITH VITAMIN C TABLET [807]
|
Facility
|
OP
|
$0.03
|
|
|
Service Code
|
NDC 9999-9998-07
|
| Hospital Charge Code |
NDC408807
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.02
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.02
|
| Rate for Payer: Blue Distinction Transplant |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO |
$0.02
|
| Rate for Payer: Cigna of CA PPO |
$0.02
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.03
|
| Rate for Payer: Dignity Health Media |
$0.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.01
|
| Rate for Payer: Galaxy Health WC |
$0.03
|
| Rate for Payer: Global Benefits Group Commercial |
$0.02
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: Networks By Design Commercial |
$0.02
|
| Rate for Payer: Prime Health Services Commercial |
$0.03
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.02
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.02
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.02
|
| Rate for Payer: United Healthcare All Other HMO |
$0.02
|
| Rate for Payer: United Healthcare HMO Rider |
$0.02
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Vantage Medical Group Senior |
$0.03
|
|
|
BEBTELOVIMAB 175 MG/2 ML (87.5 MG/ML) INTRAVENOUS SOLUTION (UNAPP) [233528]
|
Facility
|
OP
|
$1,260.00
|
|
|
Service Code
|
CPT Q0222
|
| Hospital Charge Code |
NDG233528
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$302.40 |
| Max. Negotiated Rate |
$16,643.57 |
| Rate for Payer: Aetna of CA HMO/PPO |
$16,643.57
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,924.19
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3,453.28
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3,453.28
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$750.71
|
| Rate for Payer: Blue Distinction Transplant |
$756.00
|
| Rate for Payer: Blue Shield of California Commercial |
$928.62
|
| Rate for Payer: Blue Shield of California EPN |
$735.84
|
| Rate for Payer: Cash Price |
$567.00
|
| Rate for Payer: Cash Price |
$567.00
|
| Rate for Payer: Cigna of CA HMO |
$882.00
|
| Rate for Payer: Cigna of CA PPO |
$882.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4,709.02
|
| Rate for Payer: Dignity Health Media |
$3,139.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$3,453.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$4,238.12
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$3,139.35
|
| Rate for Payer: EPIC Health Plan Transplant |
$3,139.35
|
| Rate for Payer: Galaxy Health WC |
$1,071.00
|
| Rate for Payer: Global Benefits Group Commercial |
$756.00
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$945.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$5,148.53
|
| Rate for Payer: Heritage Provider Network Transplant |
$5,148.53
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$5,085.75
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$5,085.75
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$3,139.35
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$840.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$480.06
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3,139.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$302.40
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3,955.58
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4,206.73
|
| Rate for Payer: Multiplan Commercial |
$1,008.00
|
| Rate for Payer: Networks By Design Commercial |
$630.00
|
| Rate for Payer: Prime Health Services Commercial |
$1,071.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$756.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$756.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$630.00
|
| Rate for Payer: United Healthcare All Other HMO |
$630.00
|
| Rate for Payer: United Healthcare HMO Rider |
$630.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$630.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4,709.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3,453.28
|
| Rate for Payer: Vantage Medical Group Senior |
$3,139.35
|
|
|
BEBTELOVIMAB 175 MG/2 ML (87.5 MG/ML) INTRAVENOUS SOLUTION (UNAPP) [233528]
|
Facility
|
IP
|
$1,260.00
|
|
|
Service Code
|
CPT Q0222
|
| Hospital Charge Code |
NDG233528
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$302.40 |
| Max. Negotiated Rate |
$1,071.00 |
| Rate for Payer: Blue Shield of California Commercial |
$897.12
|
| Rate for Payer: Blue Shield of California EPN |
$645.12
|
| Rate for Payer: Cash Price |
$567.00
|
| Rate for Payer: Cigna of CA HMO |
$882.00
|
| Rate for Payer: Cigna of CA PPO |
$882.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$504.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$504.00
|
| Rate for Payer: Galaxy Health WC |
$1,071.00
|
| Rate for Payer: Global Benefits Group Commercial |
$756.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$840.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$480.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$302.40
|
| Rate for Payer: Multiplan Commercial |
$1,008.00
|
| Rate for Payer: Networks By Design Commercial |
$630.00
|
| Rate for Payer: Prime Health Services Commercial |
$1,071.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$475.78
|
| Rate for Payer: United Healthcare All Other HMO |
$464.69
|
| Rate for Payer: United Healthcare HMO Rider |
$454.61
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$415.80
|
|
|
BECLOMETHASONE ORAL EMULSION COMPOUND 1 MG/ML [4080247]
|
Facility
|
IP
|
$0.09
|
|
|
Service Code
|
NDC 9994-0802-47
|
| Hospital Charge Code |
1715210
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Blue Shield of California Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO |
$0.06
|
| Rate for Payer: Cigna of CA PPO |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.08
|
| Rate for Payer: Global Benefits Group Commercial |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.07
|
| Rate for Payer: Networks By Design Commercial |
$0.06
|
| Rate for Payer: Prime Health Services Commercial |
$0.08
|
|
|
BECLOMETHASONE ORAL EMULSION COMPOUND 1 MG/ML [4080247]
|
Facility
|
OP
|
$0.09
|
|
|
Service Code
|
NDC 9994-0802-47
|
| Hospital Charge Code |
1715210
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.08
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.05
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.05
|
| Rate for Payer: Blue Distinction Transplant |
$0.05
|
| Rate for Payer: Blue Shield of California Commercial |
$0.07
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO |
$0.06
|
| Rate for Payer: Cigna of CA PPO |
$0.06
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.08
|
| Rate for Payer: Dignity Health Media |
$0.08
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.08
|
| Rate for Payer: Global Benefits Group Commercial |
$0.05
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.07
|
| Rate for Payer: Networks By Design Commercial |
$0.06
|
| Rate for Payer: Prime Health Services Commercial |
$0.08
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.05
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.05
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.05
|
| Rate for Payer: United Healthcare All Other HMO |
$0.05
|
| Rate for Payer: United Healthcare HMO Rider |
$0.05
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.05
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.08
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.08
|
| Rate for Payer: Vantage Medical Group Senior |
$0.08
|
|
|
BEER [4080757]
|
Facility
|
OP
|
$1.43
|
|
|
Service Code
|
NDC 9994-0807-57
|
| Hospital Charge Code |
ERX4080757
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.34 |
| Max. Negotiated Rate |
$1.22 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.94
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.22
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.79
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.79
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.85
|
| Rate for Payer: Blue Distinction Transplant |
$0.86
|
| Rate for Payer: Blue Shield of California Commercial |
$1.05
|
| Rate for Payer: Blue Shield of California EPN |
$0.84
|
| Rate for Payer: Cash Price |
$0.64
|
| Rate for Payer: Cigna of CA HMO |
$0.92
|
| Rate for Payer: Cigna of CA PPO |
$1.06
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.22
|
| Rate for Payer: Dignity Health Media |
$1.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.57
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.57
|
| Rate for Payer: Galaxy Health WC |
$1.22
|
| Rate for Payer: Global Benefits Group Commercial |
$0.86
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$1.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.95
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.34
|
| Rate for Payer: Multiplan Commercial |
$1.14
|
| Rate for Payer: Networks By Design Commercial |
$0.93
|
| Rate for Payer: Prime Health Services Commercial |
$1.22
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.86
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.86
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.72
|
| Rate for Payer: United Healthcare All Other HMO |
$0.72
|
| Rate for Payer: United Healthcare HMO Rider |
$0.72
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.72
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.22
|
| Rate for Payer: Vantage Medical Group Senior |
$1.22
|
|
|
BEER [4080757]
|
Facility
|
IP
|
$1.43
|
|
|
Service Code
|
NDC 9994-0807-57
|
| Hospital Charge Code |
ERX4080757
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.34 |
| Max. Negotiated Rate |
$1.22 |
| Rate for Payer: Blue Shield of California Commercial |
$1.02
|
| Rate for Payer: Blue Shield of California EPN |
$0.73
|
| Rate for Payer: Cash Price |
$0.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.57
|
| Rate for Payer: Galaxy Health WC |
$1.22
|
| Rate for Payer: Global Benefits Group Commercial |
$0.86
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.95
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.34
|
| Rate for Payer: Multiplan Commercial |
$1.14
|
| Rate for Payer: Networks By Design Commercial |
$0.93
|
| Rate for Payer: Prime Health Services Commercial |
$1.22
|
|
|
BEHAVIORAL DISORDERS
|
Facility
|
IP
|
$5,850.65
|
|
|
Service Code
|
APR-DRG 7581
|
| Min. Negotiated Rate |
$4,488.07 |
| Max. Negotiated Rate |
$5,850.65 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$4,488.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5,850.65
|
|
|
BEHAVIORAL DISORDERS
|
Facility
|
IP
|
$7,237.50
|
|
|
Service Code
|
APR-DRG 7582
|
| Min. Negotiated Rate |
$5,551.92 |
| Max. Negotiated Rate |
$7,237.50 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$5,551.92
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7,237.50
|
|
|
BEHAVIORAL DISORDERS
|
Facility
|
IP
|
$12,619.93
|
|
|
Service Code
|
APR-DRG 7583
|
| Min. Negotiated Rate |
$9,680.82 |
| Max. Negotiated Rate |
$12,619.93 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$9,680.82
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$12,619.93
|
|
|
BEHAVIORAL DISORDERS
|
Facility
|
IP
|
$16,656.33
|
|
|
Service Code
|
APR-DRG 7584
|
| Min. Negotiated Rate |
$12,777.16 |
| Max. Negotiated Rate |
$16,656.33 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$12,777.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$16,656.33
|
|
|
BELANTAMAB MAFODOTIN-BLMF 100 MG INTRAVENOUS SOLUTION [229004]
|
Facility
|
OP
|
$10,591.76
|
|
|
Service Code
|
CPT J9037
|
| Hospital Charge Code |
ERX229004
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$46.78 |
| Max. Negotiated Rate |
$9,003.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$85.72
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$58.48
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$51.46
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$51.46
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$88.20
|
| Rate for Payer: Blue Distinction Transplant |
$6,355.06
|
| Rate for Payer: Blue Shield of California Commercial |
$7,806.13
|
| Rate for Payer: Blue Shield of California EPN |
$6,185.59
|
| Rate for Payer: Cash Price |
$4,766.29
|
| Rate for Payer: Cash Price |
$4,766.29
|
| Rate for Payer: Cigna of CA HMO |
$7,414.23
|
| Rate for Payer: Cigna of CA PPO |
$7,414.23
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$58.48
|
| Rate for Payer: Dignity Health Media |
$51.46
|
| Rate for Payer: Dignity Health Medi-Cal |
$51.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$63.15
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$46.78
|
| Rate for Payer: EPIC Health Plan Transplant |
$46.78
|
| Rate for Payer: Galaxy Health WC |
$9,003.00
|
| Rate for Payer: Global Benefits Group Commercial |
$6,355.06
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$7,943.82
|
| Rate for Payer: Heritage Provider Network Commercial |
$76.72
|
| Rate for Payer: Heritage Provider Network Transplant |
$76.72
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$75.78
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$75.78
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$46.78
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$7,064.70
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$94.51
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$46.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,542.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$58.94
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$62.69
|
| Rate for Payer: Multiplan Commercial |
$8,473.41
|
| Rate for Payer: Networks By Design Commercial |
$5,295.88
|
| Rate for Payer: Prime Health Services Commercial |
$9,003.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$6,355.06
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$6,355.06
|
| Rate for Payer: United Healthcare All Other Commercial |
$5,295.88
|
| Rate for Payer: United Healthcare All Other HMO |
$5,295.88
|
| Rate for Payer: United Healthcare HMO Rider |
$5,295.88
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$5,295.88
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$58.48
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$51.46
|
| Rate for Payer: Vantage Medical Group Senior |
$51.46
|
|
|
BELANTAMAB MAFODOTIN-BLMF 100 MG INTRAVENOUS SOLUTION [229004]
|
Facility
|
IP
|
$10,591.76
|
|
|
Service Code
|
CPT J9037
|
| Hospital Charge Code |
ERX229004
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,542.02 |
| Max. Negotiated Rate |
$9,003.00 |
| Rate for Payer: Blue Shield of California Commercial |
$7,541.33
|
| Rate for Payer: Blue Shield of California EPN |
$5,422.98
|
| Rate for Payer: Cash Price |
$4,766.29
|
| Rate for Payer: Cigna of CA HMO |
$7,414.23
|
| Rate for Payer: Cigna of CA PPO |
$7,414.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$4,236.70
|
| Rate for Payer: EPIC Health Plan Transplant |
$4,236.70
|
| Rate for Payer: Galaxy Health WC |
$9,003.00
|
| Rate for Payer: Global Benefits Group Commercial |
$6,355.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$7,064.70
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4,035.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,542.02
|
| Rate for Payer: Multiplan Commercial |
$8,473.41
|
| Rate for Payer: Networks By Design Commercial |
$5,295.88
|
| Rate for Payer: Prime Health Services Commercial |
$9,003.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$3,999.45
|
| Rate for Payer: United Healthcare All Other HMO |
$3,906.24
|
| Rate for Payer: United Healthcare HMO Rider |
$3,821.51
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3,495.28
|
|
|
BELATACEPT 250 MG INTRAVENOUS SOLUTION [153042]
|
Facility
|
OP
|
$1,163.86
|
|
|
Service Code
|
CPT J0485
|
| Hospital Charge Code |
ERX153042
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.87 |
| Max. Negotiated Rate |
$989.28 |
| Rate for Payer: Aetna of CA HMO/PPO |
$24.35
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.84
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.26
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.26
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7.87
|
| Rate for Payer: Blue Distinction Transplant |
$698.32
|
| Rate for Payer: Blue Shield of California Commercial |
$857.76
|
| Rate for Payer: Blue Shield of California EPN |
$4.54
|
| Rate for Payer: Cash Price |
$523.74
|
| Rate for Payer: Cash Price |
$523.74
|
| Rate for Payer: Cigna of CA HMO |
$814.70
|
| Rate for Payer: Cigna of CA PPO |
$814.70
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.81
|
| Rate for Payer: Dignity Health Media |
$3.87
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.23
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$3.87
|
| Rate for Payer: EPIC Health Plan Transplant |
$3.87
|
| Rate for Payer: Galaxy Health WC |
$989.28
|
| Rate for Payer: Global Benefits Group Commercial |
$698.32
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$872.90
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.35
|
| Rate for Payer: Heritage Provider Network Transplant |
$6.35
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$6.28
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$6.28
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$3.87
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$776.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$15.83
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$279.33
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4.88
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5.19
|
| Rate for Payer: Multiplan Commercial |
$931.09
|
| Rate for Payer: Networks By Design Commercial |
$581.93
|
| Rate for Payer: Prime Health Services Commercial |
$989.28
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$698.32
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$698.32
|
| Rate for Payer: United Healthcare All Other Commercial |
$581.93
|
| Rate for Payer: United Healthcare All Other HMO |
$581.93
|
| Rate for Payer: United Healthcare HMO Rider |
$581.93
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$581.93
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.81
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.26
|
| Rate for Payer: Vantage Medical Group Senior |
$3.87
|
|
|
BELATACEPT 250 MG INTRAVENOUS SOLUTION [153042]
|
Facility
|
IP
|
$1,163.86
|
|
|
Service Code
|
CPT J0485
|
| Hospital Charge Code |
ERX153042
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$279.33 |
| Max. Negotiated Rate |
$989.28 |
| Rate for Payer: Blue Shield of California Commercial |
$828.67
|
| Rate for Payer: Blue Shield of California EPN |
$595.90
|
| Rate for Payer: Cash Price |
$523.74
|
| Rate for Payer: Cigna of CA HMO |
$814.70
|
| Rate for Payer: Cigna of CA PPO |
$814.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$465.54
|
| Rate for Payer: EPIC Health Plan Transplant |
$465.54
|
| Rate for Payer: Galaxy Health WC |
$989.28
|
| Rate for Payer: Global Benefits Group Commercial |
$698.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$776.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$443.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$279.33
|
| Rate for Payer: Multiplan Commercial |
$931.09
|
| Rate for Payer: Networks By Design Commercial |
$581.93
|
| Rate for Payer: Prime Health Services Commercial |
$989.28
|
| Rate for Payer: United Healthcare All Other Commercial |
$439.47
|
| Rate for Payer: United Healthcare All Other HMO |
$429.23
|
| Rate for Payer: United Healthcare HMO Rider |
$419.92
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$384.07
|
|
|
BELIMUMAB 120 MG INTRAVENOUS SOLUTION [108842]
|
Facility
|
IP
|
$707.42
|
|
|
Service Code
|
CPT J0490
|
| Hospital Charge Code |
1755787
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$169.78 |
| Max. Negotiated Rate |
$601.31 |
| Rate for Payer: Blue Shield of California Commercial |
$503.68
|
| Rate for Payer: Blue Shield of California EPN |
$362.20
|
| Rate for Payer: Cash Price |
$318.34
|
| Rate for Payer: Cigna of CA HMO |
$495.19
|
| Rate for Payer: Cigna of CA PPO |
$495.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$282.97
|
| Rate for Payer: EPIC Health Plan Transplant |
$282.97
|
| Rate for Payer: Galaxy Health WC |
$601.31
|
| Rate for Payer: Global Benefits Group Commercial |
$424.45
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$471.85
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$269.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$169.78
|
| Rate for Payer: Multiplan Commercial |
$565.94
|
| Rate for Payer: Networks By Design Commercial |
$353.71
|
| Rate for Payer: Prime Health Services Commercial |
$601.31
|
| Rate for Payer: United Healthcare All Other Commercial |
$267.12
|
| Rate for Payer: United Healthcare All Other HMO |
$260.90
|
| Rate for Payer: United Healthcare HMO Rider |
$255.24
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$233.45
|
|
|
BELIMUMAB 120 MG INTRAVENOUS SOLUTION [108842]
|
Facility
|
OP
|
$707.42
|
|
|
Service Code
|
CPT J0490
|
| Hospital Charge Code |
1755787
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$52.00 |
| Max. Negotiated Rate |
$601.31 |
| Rate for Payer: Aetna of CA HMO/PPO |
$327.05
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$65.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$57.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$57.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$78.75
|
| Rate for Payer: Blue Distinction Transplant |
$424.45
|
| Rate for Payer: Blue Shield of California Commercial |
$521.37
|
| Rate for Payer: Blue Shield of California EPN |
$54.19
|
| Rate for Payer: Cash Price |
$318.34
|
| Rate for Payer: Cash Price |
$318.34
|
| Rate for Payer: Cigna of CA HMO |
$495.19
|
| Rate for Payer: Cigna of CA PPO |
$495.19
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$78.00
|
| Rate for Payer: Dignity Health Media |
$52.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$57.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$70.20
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$52.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$52.00
|
| Rate for Payer: Galaxy Health WC |
$601.31
|
| Rate for Payer: Global Benefits Group Commercial |
$424.45
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$530.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$85.28
|
| Rate for Payer: Heritage Provider Network Transplant |
$85.28
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$84.24
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$84.24
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$52.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$471.85
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$107.27
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$52.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$169.78
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$65.52
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$69.68
|
| Rate for Payer: Multiplan Commercial |
$565.94
|
| Rate for Payer: Networks By Design Commercial |
$353.71
|
| Rate for Payer: Prime Health Services Commercial |
$601.31
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$424.45
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$424.45
|
| Rate for Payer: United Healthcare All Other Commercial |
$353.71
|
| Rate for Payer: United Healthcare All Other HMO |
$353.71
|
| Rate for Payer: United Healthcare HMO Rider |
$353.71
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$353.71
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$78.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$57.20
|
| Rate for Payer: Vantage Medical Group Senior |
$52.00
|
|
|
BELIMUMAB 400 MG INTRAVENOUS SOLUTION [108843]
|
Facility
|
OP
|
$2,357.96
|
|
|
Service Code
|
CPT J0490
|
| Hospital Charge Code |
1755788
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$52.00 |
| Max. Negotiated Rate |
$2,004.27 |
| Rate for Payer: Aetna of CA HMO/PPO |
$327.05
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$65.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$57.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$57.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$78.75
|
| Rate for Payer: Blue Distinction Transplant |
$1,414.78
|
| Rate for Payer: Blue Shield of California Commercial |
$1,737.82
|
| Rate for Payer: Blue Shield of California EPN |
$54.19
|
| Rate for Payer: Cash Price |
$1,061.08
|
| Rate for Payer: Cash Price |
$1,061.08
|
| Rate for Payer: Cigna of CA HMO |
$1,650.57
|
| Rate for Payer: Cigna of CA PPO |
$1,650.57
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$78.00
|
| Rate for Payer: Dignity Health Media |
$52.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$57.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$70.20
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$52.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$52.00
|
| Rate for Payer: Galaxy Health WC |
$2,004.27
|
| Rate for Payer: Global Benefits Group Commercial |
$1,414.78
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$1,768.47
|
| Rate for Payer: Heritage Provider Network Commercial |
$85.28
|
| Rate for Payer: Heritage Provider Network Transplant |
$85.28
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$84.24
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$84.24
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$52.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,572.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$107.27
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$52.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$565.91
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$65.52
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$69.68
|
| Rate for Payer: Multiplan Commercial |
$1,886.37
|
| Rate for Payer: Networks By Design Commercial |
$1,178.98
|
| Rate for Payer: Prime Health Services Commercial |
$2,004.27
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1,414.78
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1,414.78
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,178.98
|
| Rate for Payer: United Healthcare All Other HMO |
$1,178.98
|
| Rate for Payer: United Healthcare HMO Rider |
$1,178.98
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,178.98
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$78.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$57.20
|
| Rate for Payer: Vantage Medical Group Senior |
$52.00
|
|
|
BELIMUMAB 400 MG INTRAVENOUS SOLUTION [108843]
|
Facility
|
IP
|
$2,357.96
|
|
|
Service Code
|
CPT J0490
|
| Hospital Charge Code |
1755788
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$565.91 |
| Max. Negotiated Rate |
$2,004.27 |
| Rate for Payer: Blue Shield of California Commercial |
$1,678.87
|
| Rate for Payer: Blue Shield of California EPN |
$1,207.28
|
| Rate for Payer: Cash Price |
$1,061.08
|
| Rate for Payer: Cigna of CA HMO |
$1,650.57
|
| Rate for Payer: Cigna of CA PPO |
$1,650.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$943.18
|
| Rate for Payer: EPIC Health Plan Transplant |
$943.18
|
| Rate for Payer: Galaxy Health WC |
$2,004.27
|
| Rate for Payer: Global Benefits Group Commercial |
$1,414.78
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,572.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$898.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$565.91
|
| Rate for Payer: Multiplan Commercial |
$1,886.37
|
| Rate for Payer: Networks By Design Commercial |
$1,178.98
|
| Rate for Payer: Prime Health Services Commercial |
$2,004.27
|
| Rate for Payer: United Healthcare All Other Commercial |
$890.37
|
| Rate for Payer: United Healthcare All Other HMO |
$869.62
|
| Rate for Payer: United Healthcare HMO Rider |
$850.75
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$778.13
|
|
|
BELLADONNA ALKALOIDS-OPIUM 16.2 MG-30 MG RECTAL SUPPOSITORY [111311]
|
Facility
|
OP
|
$26.42
|
|
|
Service Code
|
NDC 0574-7045-01
|
| Hospital Charge Code |
ERX111311
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.34 |
| Max. Negotiated Rate |
$22.46 |
| Rate for Payer: Aetna of CA HMO/PPO |
$17.33
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$22.46
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$14.53
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$14.53
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$15.74
|
| Rate for Payer: Blue Distinction Transplant |
$15.85
|
| Rate for Payer: Blue Shield of California Commercial |
$19.47
|
| Rate for Payer: Blue Shield of California EPN |
$15.43
|
| Rate for Payer: Cash Price |
$11.89
|
| Rate for Payer: Cigna of CA HMO |
$18.49
|
| Rate for Payer: Cigna of CA PPO |
$18.49
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$22.46
|
| Rate for Payer: Dignity Health Media |
$22.46
|
| Rate for Payer: Dignity Health Medi-Cal |
$22.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.57
|
| Rate for Payer: EPIC Health Plan Transplant |
$10.57
|
| Rate for Payer: Galaxy Health WC |
$22.46
|
| Rate for Payer: Global Benefits Group Commercial |
$15.85
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$19.82
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$17.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.34
|
| Rate for Payer: Multiplan Commercial |
$21.14
|
| Rate for Payer: Networks By Design Commercial |
$17.17
|
| Rate for Payer: Prime Health Services Commercial |
$22.46
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$15.85
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$15.85
|
| Rate for Payer: United Healthcare All Other Commercial |
$13.21
|
| Rate for Payer: United Healthcare All Other HMO |
$13.21
|
| Rate for Payer: United Healthcare HMO Rider |
$13.21
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$13.21
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$22.46
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$22.46
|
| Rate for Payer: Vantage Medical Group Senior |
$22.46
|
|
|
BELLADONNA ALKALOIDS-OPIUM 16.2 MG-30 MG RECTAL SUPPOSITORY [111311]
|
Facility
|
OP
|
$26.42
|
|
|
Service Code
|
NDC 0574-7045-12
|
| Hospital Charge Code |
ERX111311
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.34 |
| Max. Negotiated Rate |
$22.46 |
| Rate for Payer: Aetna of CA HMO/PPO |
$17.33
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$22.46
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$14.53
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$14.53
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$15.74
|
| Rate for Payer: Blue Distinction Transplant |
$15.85
|
| Rate for Payer: Blue Shield of California Commercial |
$19.47
|
| Rate for Payer: Blue Shield of California EPN |
$15.43
|
| Rate for Payer: Cash Price |
$11.89
|
| Rate for Payer: Cigna of CA HMO |
$18.49
|
| Rate for Payer: Cigna of CA PPO |
$18.49
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$22.46
|
| Rate for Payer: Dignity Health Media |
$22.46
|
| Rate for Payer: Dignity Health Medi-Cal |
$22.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.57
|
| Rate for Payer: EPIC Health Plan Transplant |
$10.57
|
| Rate for Payer: Galaxy Health WC |
$22.46
|
| Rate for Payer: Global Benefits Group Commercial |
$15.85
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$19.82
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$17.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.34
|
| Rate for Payer: Multiplan Commercial |
$21.14
|
| Rate for Payer: Networks By Design Commercial |
$17.17
|
| Rate for Payer: Prime Health Services Commercial |
$22.46
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$15.85
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$15.85
|
| Rate for Payer: United Healthcare All Other Commercial |
$13.21
|
| Rate for Payer: United Healthcare All Other HMO |
$13.21
|
| Rate for Payer: United Healthcare HMO Rider |
$13.21
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$13.21
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$22.46
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$22.46
|
| Rate for Payer: Vantage Medical Group Senior |
$22.46
|
|
