|
ILOPROST 20 MCG/ML SOLUTION FOR NEBULIZATION [99773]
|
Facility
|
IP
|
$161.64
|
|
|
Service Code
|
NDC 66215-303-30
|
| Hospital Charge Code |
1744134
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$38.79 |
| Max. Negotiated Rate |
$137.39 |
| Rate for Payer: Blue Shield of California Commercial |
$115.09
|
| Rate for Payer: Blue Shield of California EPN |
$82.76
|
| Rate for Payer: Cash Price |
$72.74
|
| Rate for Payer: Cigna of CA HMO |
$113.15
|
| Rate for Payer: Cigna of CA PPO |
$113.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$64.66
|
| Rate for Payer: Galaxy Health WC |
$137.39
|
| Rate for Payer: Global Benefits Group Commercial |
$96.98
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$107.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$61.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$38.79
|
| Rate for Payer: Multiplan Commercial |
$129.31
|
| Rate for Payer: Networks By Design Commercial |
$105.07
|
| Rate for Payer: Prime Health Services Commercial |
$137.39
|
|
|
ILOPROST 20 MCG/ML SOLUTION FOR NEBULIZATION [99773]
|
Facility
|
OP
|
$161.64
|
|
|
Service Code
|
NDC 66215-303-00
|
| Hospital Charge Code |
1744134
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$38.79 |
| Max. Negotiated Rate |
$137.39 |
| Rate for Payer: Aetna of CA HMO/PPO |
$106.02
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$137.39
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$88.90
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$88.90
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$96.31
|
| Rate for Payer: Blue Distinction Transplant |
$96.98
|
| Rate for Payer: Blue Shield of California Commercial |
$119.13
|
| Rate for Payer: Blue Shield of California EPN |
$94.40
|
| Rate for Payer: Cash Price |
$72.74
|
| Rate for Payer: Cigna of CA HMO |
$113.15
|
| Rate for Payer: Cigna of CA PPO |
$113.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$137.39
|
| Rate for Payer: Dignity Health Media |
$137.39
|
| Rate for Payer: Dignity Health Medi-Cal |
$137.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$64.66
|
| Rate for Payer: EPIC Health Plan Transplant |
$64.66
|
| Rate for Payer: Galaxy Health WC |
$137.39
|
| Rate for Payer: Global Benefits Group Commercial |
$96.98
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$121.23
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$107.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$61.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$38.79
|
| Rate for Payer: Multiplan Commercial |
$129.31
|
| Rate for Payer: Networks By Design Commercial |
$105.07
|
| Rate for Payer: Prime Health Services Commercial |
$137.39
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$96.98
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$96.98
|
| Rate for Payer: United Healthcare All Other Commercial |
$80.82
|
| Rate for Payer: United Healthcare All Other HMO |
$80.82
|
| Rate for Payer: United Healthcare HMO Rider |
$80.82
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$80.82
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$137.39
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$137.39
|
| Rate for Payer: Vantage Medical Group Senior |
$137.39
|
|
|
ILOPROST 20 MCG/ML SOLUTION FOR NEBULIZATION [99773]
|
Facility
|
IP
|
$161.64
|
|
|
Service Code
|
NDC 66215-303-00
|
| Hospital Charge Code |
1744134
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$38.79 |
| Max. Negotiated Rate |
$137.39 |
| Rate for Payer: Blue Shield of California Commercial |
$115.09
|
| Rate for Payer: Blue Shield of California EPN |
$82.76
|
| Rate for Payer: Cash Price |
$72.74
|
| Rate for Payer: Cigna of CA HMO |
$113.15
|
| Rate for Payer: Cigna of CA PPO |
$113.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$64.66
|
| Rate for Payer: Galaxy Health WC |
$137.39
|
| Rate for Payer: Global Benefits Group Commercial |
$96.98
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$107.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$61.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$38.79
|
| Rate for Payer: Multiplan Commercial |
$129.31
|
| Rate for Payer: Networks By Design Commercial |
$105.07
|
| Rate for Payer: Prime Health Services Commercial |
$137.39
|
|
|
IMATINIB 100 MG TABLET [32979]
|
Facility
|
IP
|
$4.55
|
|
|
Service Code
|
CPT S0088
|
| Hospital Charge Code |
1711843
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.09 |
| Max. Negotiated Rate |
$3.87 |
| Rate for Payer: Blue Shield of California Commercial |
$3.24
|
| Rate for Payer: Blue Shield of California Commercial |
$1.40
|
| Rate for Payer: Blue Shield of California Commercial |
$38.16
|
| Rate for Payer: Blue Shield of California Commercial |
$1.05
|
| Rate for Payer: Blue Shield of California EPN |
$27.44
|
| Rate for Payer: Blue Shield of California EPN |
$2.33
|
| Rate for Payer: Blue Shield of California EPN |
$1.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.75
|
| Rate for Payer: Cash Price |
$2.05
|
| Rate for Payer: Cash Price |
$0.66
|
| Rate for Payer: Cash Price |
$0.89
|
| Rate for Payer: Cash Price |
$24.12
|
| Rate for Payer: Cigna of CA HMO |
$1.03
|
| Rate for Payer: Cigna of CA HMO |
$37.52
|
| Rate for Payer: Cigna of CA HMO |
$1.38
|
| Rate for Payer: Cigna of CA HMO |
$3.18
|
| Rate for Payer: Cigna of CA PPO |
$37.52
|
| Rate for Payer: Cigna of CA PPO |
$1.38
|
| Rate for Payer: Cigna of CA PPO |
$3.18
|
| Rate for Payer: Cigna of CA PPO |
$1.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$21.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.79
|
| Rate for Payer: Galaxy Health WC |
$3.87
|
| Rate for Payer: Galaxy Health WC |
$45.56
|
| Rate for Payer: Galaxy Health WC |
$1.67
|
| Rate for Payer: Galaxy Health WC |
$1.25
|
| Rate for Payer: Global Benefits Group Commercial |
$2.73
|
| Rate for Payer: Global Benefits Group Commercial |
$0.88
|
| Rate for Payer: Global Benefits Group Commercial |
$1.18
|
| Rate for Payer: Global Benefits Group Commercial |
$32.16
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$35.75
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.98
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$20.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.35
|
| Rate for Payer: Multiplan Commercial |
$1.58
|
| Rate for Payer: Multiplan Commercial |
$42.88
|
| Rate for Payer: Multiplan Commercial |
$3.64
|
| Rate for Payer: Multiplan Commercial |
$1.18
|
| Rate for Payer: Networks By Design Commercial |
$1.28
|
| Rate for Payer: Networks By Design Commercial |
$2.96
|
| Rate for Payer: Networks By Design Commercial |
$0.96
|
| Rate for Payer: Networks By Design Commercial |
$34.84
|
| Rate for Payer: Prime Health Services Commercial |
$1.25
|
| Rate for Payer: Prime Health Services Commercial |
$3.87
|
| Rate for Payer: Prime Health Services Commercial |
$1.67
|
| Rate for Payer: Prime Health Services Commercial |
$45.56
|
|
|
IMATINIB 100 MG TABLET [32979]
|
Facility
|
OP
|
$4.55
|
|
|
Service Code
|
CPT S0088
|
| Hospital Charge Code |
1711843
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.09 |
| Max. Negotiated Rate |
$133.83 |
| Rate for Payer: Aetna of CA HMO/PPO |
$19.37
|
| Rate for Payer: Aetna of CA HMO/PPO |
$19.37
|
| Rate for Payer: Aetna of CA HMO/PPO |
$19.37
|
| Rate for Payer: Aetna of CA HMO/PPO |
$19.37
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.67
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$45.56
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.87
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.25
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.08
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.50
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.81
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$29.48
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.08
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.81
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$29.48
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$133.83
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$133.83
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$133.83
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$133.83
|
| Rate for Payer: Blue Distinction Transplant |
$32.16
|
| Rate for Payer: Blue Distinction Transplant |
$0.88
|
| Rate for Payer: Blue Distinction Transplant |
$1.18
|
| Rate for Payer: Blue Distinction Transplant |
$2.73
|
| Rate for Payer: Blue Shield of California Commercial |
$39.50
|
| Rate for Payer: Blue Shield of California Commercial |
$1.08
|
| Rate for Payer: Blue Shield of California Commercial |
$1.45
|
| Rate for Payer: Blue Shield of California Commercial |
$3.35
|
| Rate for Payer: Blue Shield of California EPN |
$31.30
|
| Rate for Payer: Blue Shield of California EPN |
$2.66
|
| Rate for Payer: Blue Shield of California EPN |
$0.86
|
| Rate for Payer: Blue Shield of California EPN |
$1.15
|
| Rate for Payer: Cash Price |
$0.89
|
| Rate for Payer: Cash Price |
$2.05
|
| Rate for Payer: Cash Price |
$0.66
|
| Rate for Payer: Cash Price |
$0.66
|
| Rate for Payer: Cash Price |
$0.89
|
| Rate for Payer: Cash Price |
$24.12
|
| Rate for Payer: Cash Price |
$24.12
|
| Rate for Payer: Cash Price |
$2.05
|
| Rate for Payer: Cigna of CA HMO |
$37.52
|
| Rate for Payer: Cigna of CA HMO |
$1.03
|
| Rate for Payer: Cigna of CA HMO |
$1.38
|
| Rate for Payer: Cigna of CA HMO |
$3.18
|
| Rate for Payer: Cigna of CA PPO |
$3.18
|
| Rate for Payer: Cigna of CA PPO |
$1.38
|
| Rate for Payer: Cigna of CA PPO |
$37.52
|
| Rate for Payer: Cigna of CA PPO |
$1.03
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.67
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$45.56
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.87
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.25
|
| Rate for Payer: Dignity Health Media |
$1.67
|
| Rate for Payer: Dignity Health Media |
$45.56
|
| Rate for Payer: Dignity Health Media |
$3.87
|
| Rate for Payer: Dignity Health Media |
$1.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$45.56
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.67
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.79
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$21.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.82
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.79
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.82
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.59
|
| Rate for Payer: EPIC Health Plan Transplant |
$21.44
|
| Rate for Payer: Galaxy Health WC |
$45.56
|
| Rate for Payer: Galaxy Health WC |
$1.67
|
| Rate for Payer: Galaxy Health WC |
$1.25
|
| Rate for Payer: Galaxy Health WC |
$3.87
|
| Rate for Payer: Global Benefits Group Commercial |
$2.73
|
| Rate for Payer: Global Benefits Group Commercial |
$32.16
|
| Rate for Payer: Global Benefits Group Commercial |
$0.88
|
| Rate for Payer: Global Benefits Group Commercial |
$1.18
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$1.48
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$3.41
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$40.20
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$1.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.98
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.31
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$35.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$20.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.09
|
| Rate for Payer: Multiplan Commercial |
$1.58
|
| Rate for Payer: Multiplan Commercial |
$3.64
|
| Rate for Payer: Multiplan Commercial |
$42.88
|
| Rate for Payer: Multiplan Commercial |
$1.18
|
| Rate for Payer: Networks By Design Commercial |
$1.28
|
| Rate for Payer: Networks By Design Commercial |
$34.84
|
| Rate for Payer: Networks By Design Commercial |
$2.96
|
| Rate for Payer: Networks By Design Commercial |
$0.96
|
| Rate for Payer: Prime Health Services Commercial |
$3.87
|
| Rate for Payer: Prime Health Services Commercial |
$1.25
|
| Rate for Payer: Prime Health Services Commercial |
$1.67
|
| Rate for Payer: Prime Health Services Commercial |
$45.56
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$32.16
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.73
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.18
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.88
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.18
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.73
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.88
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$32.16
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.74
|
| Rate for Payer: United Healthcare All Other Commercial |
$26.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.28
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.99
|
| Rate for Payer: United Healthcare All Other HMO |
$0.74
|
| Rate for Payer: United Healthcare All Other HMO |
$26.80
|
| Rate for Payer: United Healthcare All Other HMO |
$0.99
|
| Rate for Payer: United Healthcare All Other HMO |
$2.28
|
| Rate for Payer: United Healthcare HMO Rider |
$26.80
|
| Rate for Payer: United Healthcare HMO Rider |
$2.28
|
| Rate for Payer: United Healthcare HMO Rider |
$0.74
|
| Rate for Payer: United Healthcare HMO Rider |
$0.99
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$26.80
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.99
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.74
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.28
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$45.56
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.25
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.87
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.67
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.67
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$45.56
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.87
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.25
|
| Rate for Payer: Vantage Medical Group Senior |
$1.67
|
| Rate for Payer: Vantage Medical Group Senior |
$45.56
|
| Rate for Payer: Vantage Medical Group Senior |
$1.25
|
| Rate for Payer: Vantage Medical Group Senior |
$3.87
|
|
|
IMATINIB 400 MG TABLET [36092]
|
Facility
|
OP
|
$16.38
|
|
|
Service Code
|
CPT S0088
|
| Hospital Charge Code |
1711842
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.93 |
| Max. Negotiated Rate |
$133.83 |
| Rate for Payer: Aetna of CA HMO/PPO |
$19.37
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$13.92
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$9.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9.01
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$133.83
|
| Rate for Payer: Blue Distinction Transplant |
$9.83
|
| Rate for Payer: Blue Shield of California Commercial |
$12.07
|
| Rate for Payer: Blue Shield of California EPN |
$9.57
|
| Rate for Payer: Cash Price |
$7.37
|
| Rate for Payer: Cash Price |
$7.37
|
| Rate for Payer: Cigna of CA HMO |
$11.47
|
| Rate for Payer: Cigna of CA PPO |
$11.47
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$13.92
|
| Rate for Payer: Dignity Health Media |
$13.92
|
| Rate for Payer: Dignity Health Medi-Cal |
$13.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.55
|
| Rate for Payer: EPIC Health Plan Transplant |
$6.55
|
| Rate for Payer: Galaxy Health WC |
$13.92
|
| Rate for Payer: Global Benefits Group Commercial |
$9.83
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$12.28
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$10.93
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.93
|
| Rate for Payer: Multiplan Commercial |
$13.10
|
| Rate for Payer: Networks By Design Commercial |
$10.65
|
| Rate for Payer: Prime Health Services Commercial |
$13.92
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$9.83
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$9.83
|
| Rate for Payer: United Healthcare All Other Commercial |
$8.19
|
| Rate for Payer: United Healthcare All Other HMO |
$8.19
|
| Rate for Payer: United Healthcare HMO Rider |
$8.19
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$8.19
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$13.92
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$13.92
|
| Rate for Payer: Vantage Medical Group Senior |
$13.92
|
|
|
IMATINIB 400 MG TABLET [36092]
|
Facility
|
IP
|
$16.38
|
|
|
Service Code
|
CPT S0088
|
| Hospital Charge Code |
1711842
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.93 |
| Max. Negotiated Rate |
$13.92 |
| Rate for Payer: Blue Shield of California Commercial |
$11.66
|
| Rate for Payer: Blue Shield of California EPN |
$8.39
|
| Rate for Payer: Cash Price |
$7.37
|
| Rate for Payer: Cigna of CA HMO |
$11.47
|
| Rate for Payer: Cigna of CA PPO |
$11.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.55
|
| Rate for Payer: Galaxy Health WC |
$13.92
|
| Rate for Payer: Global Benefits Group Commercial |
$9.83
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$10.93
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.93
|
| Rate for Payer: Multiplan Commercial |
$13.10
|
| Rate for Payer: Networks By Design Commercial |
$10.65
|
| Rate for Payer: Prime Health Services Commercial |
$13.92
|
|
|
IMIPENEM-CILASTATIN 250 MG INTRAVENOUS SOLUTION [9602]
|
Facility
|
IP
|
$17.99
|
|
|
Service Code
|
CPT J0743
|
| Hospital Charge Code |
ERX9602
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.32 |
| Max. Negotiated Rate |
$15.29 |
| Rate for Payer: Blue Shield of California Commercial |
$12.81
|
| Rate for Payer: Blue Shield of California EPN |
$9.21
|
| Rate for Payer: Cash Price |
$8.10
|
| Rate for Payer: Cigna of CA HMO |
$12.59
|
| Rate for Payer: Cigna of CA PPO |
$12.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.20
|
| Rate for Payer: EPIC Health Plan Transplant |
$7.20
|
| Rate for Payer: Galaxy Health WC |
$15.29
|
| Rate for Payer: Global Benefits Group Commercial |
$10.79
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$12.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.32
|
| Rate for Payer: Multiplan Commercial |
$14.39
|
| Rate for Payer: Networks By Design Commercial |
$9.00
|
| Rate for Payer: Prime Health Services Commercial |
$15.29
|
| Rate for Payer: United Healthcare All Other Commercial |
$6.79
|
| Rate for Payer: United Healthcare All Other HMO |
$6.63
|
| Rate for Payer: United Healthcare HMO Rider |
$6.49
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$5.94
|
|
|
IMIPENEM-CILASTATIN 250 MG INTRAVENOUS SOLUTION [9602]
|
Facility
|
OP
|
$17.99
|
|
|
Service Code
|
CPT J0743
|
| Hospital Charge Code |
ERX9602
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.32 |
| Max. Negotiated Rate |
$50.94 |
| Rate for Payer: Aetna of CA HMO/PPO |
$50.94
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$15.29
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$9.89
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9.89
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$30.26
|
| Rate for Payer: Blue Distinction Transplant |
$10.79
|
| Rate for Payer: Blue Shield of California Commercial |
$13.26
|
| Rate for Payer: Blue Shield of California EPN |
$10.56
|
| Rate for Payer: Cash Price |
$8.10
|
| Rate for Payer: Cash Price |
$8.10
|
| Rate for Payer: Cigna of CA HMO |
$12.59
|
| Rate for Payer: Cigna of CA PPO |
$12.59
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$15.29
|
| Rate for Payer: Dignity Health Media |
$15.29
|
| Rate for Payer: Dignity Health Medi-Cal |
$15.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.20
|
| Rate for Payer: EPIC Health Plan Transplant |
$7.20
|
| Rate for Payer: Galaxy Health WC |
$15.29
|
| Rate for Payer: Global Benefits Group Commercial |
$10.79
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$13.49
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$12.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.32
|
| Rate for Payer: Multiplan Commercial |
$14.39
|
| Rate for Payer: Networks By Design Commercial |
$9.00
|
| Rate for Payer: Prime Health Services Commercial |
$15.29
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$10.79
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$10.79
|
| Rate for Payer: United Healthcare All Other Commercial |
$9.00
|
| Rate for Payer: United Healthcare All Other HMO |
$9.00
|
| Rate for Payer: United Healthcare HMO Rider |
$9.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$9.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$15.29
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$15.29
|
| Rate for Payer: Vantage Medical Group Senior |
$15.29
|
|
|
IMIPENEM-CILASTATIN 500 MG INTRAVENOUS SOLUTION [9603]
|
Facility
|
OP
|
$35.98
|
|
|
Service Code
|
CPT J0743
|
| Hospital Charge Code |
1753116
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.64 |
| Max. Negotiated Rate |
$50.94 |
| Rate for Payer: Aetna of CA HMO/PPO |
$50.94
|
| Rate for Payer: Aetna of CA HMO/PPO |
$50.94
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$30.58
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$27.90
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$19.79
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$18.05
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$18.05
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$19.79
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$30.26
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$30.26
|
| Rate for Payer: Blue Distinction Transplant |
$21.59
|
| Rate for Payer: Blue Distinction Transplant |
$19.69
|
| Rate for Payer: Blue Shield of California Commercial |
$24.19
|
| Rate for Payer: Blue Shield of California Commercial |
$26.52
|
| Rate for Payer: Blue Shield of California EPN |
$10.56
|
| Rate for Payer: Blue Shield of California EPN |
$10.56
|
| Rate for Payer: Cash Price |
$14.77
|
| Rate for Payer: Cash Price |
$14.77
|
| Rate for Payer: Cash Price |
$16.19
|
| Rate for Payer: Cash Price |
$16.19
|
| Rate for Payer: Cigna of CA HMO |
$25.19
|
| Rate for Payer: Cigna of CA HMO |
$22.97
|
| Rate for Payer: Cigna of CA PPO |
$25.19
|
| Rate for Payer: Cigna of CA PPO |
$22.97
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$27.90
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$30.58
|
| Rate for Payer: Dignity Health Media |
$30.58
|
| Rate for Payer: Dignity Health Media |
$27.90
|
| Rate for Payer: Dignity Health Medi-Cal |
$27.90
|
| Rate for Payer: Dignity Health Medi-Cal |
$30.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$13.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.39
|
| Rate for Payer: EPIC Health Plan Transplant |
$13.13
|
| Rate for Payer: EPIC Health Plan Transplant |
$14.39
|
| Rate for Payer: Galaxy Health WC |
$30.58
|
| Rate for Payer: Galaxy Health WC |
$27.90
|
| Rate for Payer: Global Benefits Group Commercial |
$19.69
|
| Rate for Payer: Global Benefits Group Commercial |
$21.59
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$24.62
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$26.98
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$21.89
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$24.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$13.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$12.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.64
|
| Rate for Payer: Multiplan Commercial |
$28.78
|
| Rate for Payer: Multiplan Commercial |
$26.26
|
| Rate for Payer: Networks By Design Commercial |
$16.41
|
| Rate for Payer: Networks By Design Commercial |
$17.99
|
| Rate for Payer: Prime Health Services Commercial |
$30.58
|
| Rate for Payer: Prime Health Services Commercial |
$27.90
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$21.59
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$19.69
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$19.69
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$21.59
|
| Rate for Payer: United Healthcare All Other Commercial |
$16.41
|
| Rate for Payer: United Healthcare All Other Commercial |
$17.99
|
| Rate for Payer: United Healthcare All Other HMO |
$17.99
|
| Rate for Payer: United Healthcare All Other HMO |
$16.41
|
| Rate for Payer: United Healthcare HMO Rider |
$17.99
|
| Rate for Payer: United Healthcare HMO Rider |
$16.41
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$16.41
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$17.99
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$27.90
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$30.58
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$27.90
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$30.58
|
| Rate for Payer: Vantage Medical Group Senior |
$30.58
|
| Rate for Payer: Vantage Medical Group Senior |
$27.90
|
|
|
IMIPENEM-CILASTATIN 500 MG INTRAVENOUS SOLUTION [9603]
|
Facility
|
IP
|
$32.82
|
|
|
Service Code
|
CPT J0743
|
| Hospital Charge Code |
1753116
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.88 |
| Max. Negotiated Rate |
$27.90 |
| Rate for Payer: Blue Shield of California Commercial |
$23.37
|
| Rate for Payer: Blue Shield of California Commercial |
$25.62
|
| Rate for Payer: Blue Shield of California EPN |
$16.80
|
| Rate for Payer: Blue Shield of California EPN |
$18.42
|
| Rate for Payer: Cash Price |
$14.77
|
| Rate for Payer: Cash Price |
$16.19
|
| Rate for Payer: Cigna of CA HMO |
$22.97
|
| Rate for Payer: Cigna of CA HMO |
$25.19
|
| Rate for Payer: Cigna of CA PPO |
$25.19
|
| Rate for Payer: Cigna of CA PPO |
$22.97
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$13.13
|
| Rate for Payer: EPIC Health Plan Transplant |
$13.13
|
| Rate for Payer: EPIC Health Plan Transplant |
$14.39
|
| Rate for Payer: Galaxy Health WC |
$27.90
|
| Rate for Payer: Galaxy Health WC |
$30.58
|
| Rate for Payer: Global Benefits Group Commercial |
$21.59
|
| Rate for Payer: Global Benefits Group Commercial |
$19.69
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$24.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$21.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$12.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$13.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.64
|
| Rate for Payer: Multiplan Commercial |
$26.26
|
| Rate for Payer: Multiplan Commercial |
$28.78
|
| Rate for Payer: Networks By Design Commercial |
$16.41
|
| Rate for Payer: Networks By Design Commercial |
$17.99
|
| Rate for Payer: Prime Health Services Commercial |
$27.90
|
| Rate for Payer: Prime Health Services Commercial |
$30.58
|
| Rate for Payer: United Healthcare All Other Commercial |
$12.39
|
| Rate for Payer: United Healthcare All Other Commercial |
$13.59
|
| Rate for Payer: United Healthcare All Other HMO |
$12.10
|
| Rate for Payer: United Healthcare All Other HMO |
$13.27
|
| Rate for Payer: United Healthcare HMO Rider |
$11.84
|
| Rate for Payer: United Healthcare HMO Rider |
$12.98
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$10.83
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$11.87
|
|
|
IMIPRAMINE 10 MG TABLET [3860]
|
Facility
|
OP
|
$0.22
|
|
|
Service Code
|
NDC 69315-133-01
|
| Hospital Charge Code |
1711106
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.19 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.19
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.12
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.13
|
| Rate for Payer: Blue Distinction Transplant |
$0.13
|
| Rate for Payer: Blue Shield of California Commercial |
$0.16
|
| Rate for Payer: Blue Shield of California EPN |
$0.13
|
| Rate for Payer: Cash Price |
$0.10
|
| 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 |
$0.19
|
| Rate for Payer: Dignity Health Media |
$0.19
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.09
|
| Rate for Payer: Galaxy Health WC |
$0.19
|
| Rate for Payer: Global Benefits Group Commercial |
$0.13
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.15
|
| 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 |
$0.18
|
| Rate for Payer: Networks By Design Commercial |
$0.14
|
| Rate for Payer: Prime Health Services Commercial |
$0.19
|
| 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 |
$0.19
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.19
|
| Rate for Payer: Vantage Medical Group Senior |
$0.19
|
|
|
IMIPRAMINE 10 MG TABLET [3860]
|
Facility
|
IP
|
$0.22
|
|
|
Service Code
|
NDC 69315-133-01
|
| Hospital Charge Code |
1711106
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.19 |
| Rate for Payer: Blue Shield of California Commercial |
$0.16
|
| Rate for Payer: Blue Shield of California EPN |
$0.11
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cigna of CA HMO |
$0.15
|
| Rate for Payer: Cigna of CA PPO |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: Galaxy Health WC |
$0.19
|
| Rate for Payer: Global Benefits Group Commercial |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.15
|
| 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 |
$0.18
|
| Rate for Payer: Networks By Design Commercial |
$0.14
|
| Rate for Payer: Prime Health Services Commercial |
$0.19
|
|
|
IMIPRAMINE 25 MG TABLET [3861]
|
Facility
|
IP
|
$0.41
|
|
|
Service Code
|
NDC 0781-1764-01
|
| Hospital Charge Code |
1711197
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.35 |
| Rate for Payer: Blue Shield of California Commercial |
$0.29
|
| Rate for Payer: Blue Shield of California EPN |
$0.21
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Cigna of CA HMO |
$0.29
|
| Rate for Payer: Cigna of CA PPO |
$0.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| Rate for Payer: Galaxy Health WC |
$0.35
|
| Rate for Payer: Global Benefits Group Commercial |
$0.25
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.33
|
| Rate for Payer: Networks By Design Commercial |
$0.27
|
| Rate for Payer: Prime Health Services Commercial |
$0.35
|
|
|
IMIPRAMINE 25 MG TABLET [3861]
|
Facility
|
IP
|
$0.29
|
|
|
Service Code
|
NDC 49884-055-01
|
| Hospital Charge Code |
1711197
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.25 |
| Rate for Payer: Blue Shield of California Commercial |
$0.21
|
| Rate for Payer: Blue Shield of California EPN |
$0.15
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Cigna of CA HMO |
$0.20
|
| Rate for Payer: Cigna of CA PPO |
$0.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: Galaxy Health WC |
$0.25
|
| Rate for Payer: Global Benefits Group Commercial |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
| Rate for Payer: Networks By Design Commercial |
$0.19
|
| Rate for Payer: Prime Health Services Commercial |
$0.25
|
|
|
IMIPRAMINE 25 MG TABLET [3861]
|
Facility
|
OP
|
$0.29
|
|
|
Service Code
|
NDC 69315-134-01
|
| Hospital Charge Code |
1711197
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.25 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.19
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.25
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.16
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.16
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.17
|
| Rate for Payer: Blue Distinction Transplant |
$0.17
|
| Rate for Payer: Blue Shield of California Commercial |
$0.21
|
| Rate for Payer: Blue Shield of California EPN |
$0.17
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Cigna of CA HMO |
$0.20
|
| Rate for Payer: Cigna of CA PPO |
$0.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.25
|
| Rate for Payer: Dignity Health Media |
$0.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.12
|
| Rate for Payer: Galaxy Health WC |
$0.25
|
| Rate for Payer: Global Benefits Group Commercial |
$0.17
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
| Rate for Payer: Networks By Design Commercial |
$0.19
|
| Rate for Payer: Prime Health Services Commercial |
$0.25
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.17
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.17
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.15
|
| Rate for Payer: United Healthcare All Other HMO |
$0.15
|
| Rate for Payer: United Healthcare HMO Rider |
$0.15
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.15
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.25
|
| Rate for Payer: Vantage Medical Group Senior |
$0.25
|
|
|
IMIPRAMINE 25 MG TABLET [3861]
|
Facility
|
IP
|
$0.29
|
|
|
Service Code
|
NDC 69315-134-01
|
| Hospital Charge Code |
1711197
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.25 |
| Rate for Payer: Blue Shield of California Commercial |
$0.21
|
| Rate for Payer: Blue Shield of California EPN |
$0.15
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Cigna of CA HMO |
$0.20
|
| Rate for Payer: Cigna of CA PPO |
$0.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: Galaxy Health WC |
$0.25
|
| Rate for Payer: Global Benefits Group Commercial |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
| Rate for Payer: Networks By Design Commercial |
$0.19
|
| Rate for Payer: Prime Health Services Commercial |
$0.25
|
|
|
IMIPRAMINE 25 MG TABLET [3861]
|
Facility
|
OP
|
$0.29
|
|
|
Service Code
|
NDC 49884-055-01
|
| Hospital Charge Code |
1711197
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.25 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.19
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.25
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.16
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.16
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.17
|
| Rate for Payer: Blue Distinction Transplant |
$0.17
|
| Rate for Payer: Blue Shield of California Commercial |
$0.21
|
| Rate for Payer: Blue Shield of California EPN |
$0.17
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Cigna of CA HMO |
$0.20
|
| Rate for Payer: Cigna of CA PPO |
$0.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.25
|
| Rate for Payer: Dignity Health Media |
$0.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.12
|
| Rate for Payer: Galaxy Health WC |
$0.25
|
| Rate for Payer: Global Benefits Group Commercial |
$0.17
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
| Rate for Payer: Networks By Design Commercial |
$0.19
|
| Rate for Payer: Prime Health Services Commercial |
$0.25
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.17
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.17
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.15
|
| Rate for Payer: United Healthcare All Other HMO |
$0.15
|
| Rate for Payer: United Healthcare HMO Rider |
$0.15
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.15
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.25
|
| Rate for Payer: Vantage Medical Group Senior |
$0.25
|
|
|
IMIPRAMINE 25 MG TABLET [3861]
|
Facility
|
OP
|
$0.41
|
|
|
Service Code
|
NDC 0781-1764-01
|
| Hospital Charge Code |
1711197
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.35 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.27
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.35
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.23
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.23
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.24
|
| Rate for Payer: Blue Distinction Transplant |
$0.25
|
| Rate for Payer: Blue Shield of California Commercial |
$0.30
|
| Rate for Payer: Blue Shield of California EPN |
$0.24
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Cigna of CA HMO |
$0.29
|
| Rate for Payer: Cigna of CA PPO |
$0.29
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.35
|
| Rate for Payer: Dignity Health Media |
$0.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.16
|
| Rate for Payer: Galaxy Health WC |
$0.35
|
| Rate for Payer: Global Benefits Group Commercial |
$0.25
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.31
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.33
|
| Rate for Payer: Networks By Design Commercial |
$0.27
|
| Rate for Payer: Prime Health Services Commercial |
$0.35
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.25
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.25
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.21
|
| Rate for Payer: United Healthcare All Other HMO |
$0.21
|
| Rate for Payer: United Healthcare HMO Rider |
$0.21
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.21
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.35
|
| Rate for Payer: Vantage Medical Group Senior |
$0.35
|
|
|
IMIQUIMOD 5 % TOPICAL CREAM PACKET [20718]
|
Facility
|
OP
|
$2.50
|
|
|
Service Code
|
NDC 45802-368-00
|
| Hospital Charge Code |
1743682
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$2.12 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.64
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.12
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.38
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.38
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.49
|
| Rate for Payer: Blue Distinction Transplant |
$1.50
|
| Rate for Payer: Blue Shield of California Commercial |
$1.84
|
| Rate for Payer: Blue Shield of California EPN |
$1.46
|
| Rate for Payer: Cash Price |
$1.13
|
| Rate for Payer: Cigna of CA HMO |
$1.75
|
| Rate for Payer: Cigna of CA PPO |
$1.75
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.12
|
| Rate for Payer: Dignity Health Media |
$2.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.00
|
| Rate for Payer: Galaxy Health WC |
$2.12
|
| Rate for Payer: Global Benefits Group Commercial |
$1.50
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$1.88
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.60
|
| Rate for Payer: Multiplan Commercial |
$2.00
|
| Rate for Payer: Networks By Design Commercial |
$1.62
|
| Rate for Payer: Prime Health Services Commercial |
$2.12
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.50
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.50
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.25
|
| Rate for Payer: United Healthcare All Other HMO |
$1.25
|
| Rate for Payer: United Healthcare HMO Rider |
$1.25
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.25
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.12
|
| Rate for Payer: Vantage Medical Group Senior |
$2.12
|
|
|
IMIQUIMOD 5 % TOPICAL CREAM PACKET [20718]
|
Facility
|
IP
|
$8.50
|
|
|
Service Code
|
NDC 99207-260-12
|
| Hospital Charge Code |
1743682
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.04 |
| Max. Negotiated Rate |
$7.22 |
| Rate for Payer: Blue Shield of California Commercial |
$6.05
|
| Rate for Payer: Blue Shield of California EPN |
$4.35
|
| Rate for Payer: Cash Price |
$3.83
|
| Rate for Payer: Cigna of CA HMO |
$5.95
|
| Rate for Payer: Cigna of CA PPO |
$5.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.40
|
| Rate for Payer: Galaxy Health WC |
$7.22
|
| Rate for Payer: Global Benefits Group Commercial |
$5.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.04
|
| Rate for Payer: Multiplan Commercial |
$6.80
|
| Rate for Payer: Networks By Design Commercial |
$5.52
|
| Rate for Payer: Prime Health Services Commercial |
$7.22
|
|
|
IMIQUIMOD 5 % TOPICAL CREAM PACKET [20718]
|
Facility
|
OP
|
$7.50
|
|
|
Service Code
|
NDC 0168-0432-24
|
| Hospital Charge Code |
1743682
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.80 |
| Max. Negotiated Rate |
$6.38 |
| Rate for Payer: Aetna of CA HMO/PPO |
$4.92
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.38
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.12
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.47
|
| Rate for Payer: Blue Distinction Transplant |
$4.50
|
| Rate for Payer: Blue Shield of California Commercial |
$5.53
|
| Rate for Payer: Blue Shield of California EPN |
$4.38
|
| Rate for Payer: Cash Price |
$3.38
|
| Rate for Payer: Cigna of CA HMO |
$5.25
|
| Rate for Payer: Cigna of CA PPO |
$5.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.38
|
| Rate for Payer: Dignity Health Media |
$6.38
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$3.00
|
| Rate for Payer: Galaxy Health WC |
$6.38
|
| Rate for Payer: Global Benefits Group Commercial |
$4.50
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$5.62
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.80
|
| Rate for Payer: Multiplan Commercial |
$6.00
|
| Rate for Payer: Networks By Design Commercial |
$4.88
|
| Rate for Payer: Prime Health Services Commercial |
$6.38
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$4.50
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$4.50
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.75
|
| Rate for Payer: United Healthcare All Other HMO |
$3.75
|
| Rate for Payer: United Healthcare HMO Rider |
$3.75
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.75
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6.38
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.38
|
| Rate for Payer: Vantage Medical Group Senior |
$6.38
|
|
|
IMIQUIMOD 5 % TOPICAL CREAM PACKET [20718]
|
Facility
|
IP
|
$7.50
|
|
|
Service Code
|
NDC 0168-0432-24
|
| Hospital Charge Code |
1743682
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.80 |
| Max. Negotiated Rate |
$6.38 |
| Rate for Payer: Blue Shield of California Commercial |
$5.34
|
| Rate for Payer: Blue Shield of California EPN |
$3.84
|
| Rate for Payer: Cash Price |
$3.38
|
| Rate for Payer: Cigna of CA HMO |
$5.25
|
| Rate for Payer: Cigna of CA PPO |
$5.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.00
|
| Rate for Payer: Galaxy Health WC |
$6.38
|
| Rate for Payer: Global Benefits Group Commercial |
$4.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.80
|
| Rate for Payer: Multiplan Commercial |
$6.00
|
| Rate for Payer: Networks By Design Commercial |
$4.88
|
| Rate for Payer: Prime Health Services Commercial |
$6.38
|
|
|
IMIQUIMOD 5 % TOPICAL CREAM PACKET [20718]
|
Facility
|
IP
|
$2.50
|
|
|
Service Code
|
NDC 45802-368-00
|
| Hospital Charge Code |
1743682
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$2.12 |
| Rate for Payer: Blue Shield of California Commercial |
$1.78
|
| Rate for Payer: Blue Shield of California EPN |
$1.28
|
| Rate for Payer: Cash Price |
$1.13
|
| Rate for Payer: Cigna of CA HMO |
$1.75
|
| Rate for Payer: Cigna of CA PPO |
$1.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.00
|
| Rate for Payer: Galaxy Health WC |
$2.12
|
| Rate for Payer: Global Benefits Group Commercial |
$1.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.60
|
| Rate for Payer: Multiplan Commercial |
$2.00
|
| Rate for Payer: Networks By Design Commercial |
$1.62
|
| Rate for Payer: Prime Health Services Commercial |
$2.12
|
|
|
IMIQUIMOD 5 % TOPICAL CREAM PACKET [20718]
|
Facility
|
OP
|
$8.50
|
|
|
Service Code
|
NDC 99207-260-12
|
| Hospital Charge Code |
1743682
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.04 |
| Max. Negotiated Rate |
$7.22 |
| Rate for Payer: Aetna of CA HMO/PPO |
$5.58
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$7.22
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.68
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.68
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5.06
|
| Rate for Payer: Blue Distinction Transplant |
$5.10
|
| Rate for Payer: Blue Shield of California Commercial |
$6.26
|
| Rate for Payer: Blue Shield of California EPN |
$4.96
|
| Rate for Payer: Cash Price |
$3.83
|
| Rate for Payer: Cigna of CA HMO |
$5.95
|
| Rate for Payer: Cigna of CA PPO |
$5.95
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.22
|
| Rate for Payer: Dignity Health Media |
$7.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.40
|
| Rate for Payer: EPIC Health Plan Transplant |
$3.40
|
| Rate for Payer: Galaxy Health WC |
$7.22
|
| Rate for Payer: Global Benefits Group Commercial |
$5.10
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$6.38
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.04
|
| Rate for Payer: Multiplan Commercial |
$6.80
|
| Rate for Payer: Networks By Design Commercial |
$5.52
|
| Rate for Payer: Prime Health Services Commercial |
$7.22
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$5.10
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$5.10
|
| Rate for Payer: United Healthcare All Other Commercial |
$4.25
|
| Rate for Payer: United Healthcare All Other HMO |
$4.25
|
| Rate for Payer: United Healthcare HMO Rider |
$4.25
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4.25
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.22
|
| Rate for Payer: Vantage Medical Group Senior |
$7.22
|
|
