|
INDOMETHACIN 50 MG CAPSULE [3898]
|
Facility
|
IP
|
$0.33
|
|
|
Service Code
|
NDC 68462-302-01
|
| Hospital Charge Code |
1710382
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.28 |
| Rate for Payer: Blue Shield of California Commercial |
$0.23
|
| Rate for Payer: Blue Shield of California EPN |
$0.17
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Cigna of CA HMO |
$0.23
|
| Rate for Payer: Cigna of CA PPO |
$0.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.13
|
| Rate for Payer: Galaxy Health WC |
$0.28
|
| Rate for Payer: Global Benefits Group Commercial |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
| Rate for Payer: Networks By Design Commercial |
$0.21
|
| Rate for Payer: Prime Health Services Commercial |
$0.28
|
|
|
INDOMETHACIN 50 MG CAPSULE [3898]
|
Facility
|
OP
|
$0.39
|
|
|
Service Code
|
NDC 50268-431-11
|
| Hospital Charge Code |
1710382
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.33 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.26
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.33
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.21
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.21
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.23
|
| Rate for Payer: Blue Distinction Transplant |
$0.23
|
| Rate for Payer: Blue Shield of California Commercial |
$0.29
|
| Rate for Payer: Blue Shield of California EPN |
$0.23
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Cigna of CA HMO |
$0.27
|
| Rate for Payer: Cigna of CA PPO |
$0.27
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.33
|
| Rate for Payer: Dignity Health Media |
$0.33
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.16
|
| Rate for Payer: Galaxy Health WC |
$0.33
|
| Rate for Payer: Global Benefits Group Commercial |
$0.23
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.31
|
| Rate for Payer: Networks By Design Commercial |
$0.25
|
| Rate for Payer: Prime Health Services Commercial |
$0.33
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.23
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.23
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.20
|
| Rate for Payer: United Healthcare All Other HMO |
$0.20
|
| Rate for Payer: United Healthcare HMO Rider |
$0.20
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.20
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.33
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.33
|
| Rate for Payer: Vantage Medical Group Senior |
$0.33
|
|
|
INDOMETHACIN 50 MG CAPSULE [3898]
|
Facility
|
IP
|
$0.39
|
|
|
Service Code
|
NDC 50268-431-11
|
| Hospital Charge Code |
1710382
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.33 |
| Rate for Payer: Blue Shield of California Commercial |
$0.28
|
| Rate for Payer: Blue Shield of California EPN |
$0.20
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Cigna of CA HMO |
$0.27
|
| Rate for Payer: Cigna of CA PPO |
$0.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| Rate for Payer: Galaxy Health WC |
$0.33
|
| Rate for Payer: Global Benefits Group Commercial |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.31
|
| Rate for Payer: Networks By Design Commercial |
$0.25
|
| Rate for Payer: Prime Health Services Commercial |
$0.33
|
|
|
INDOMETHACIN 50 MG RECTAL SUPPOSITORY [3901]
|
Facility
|
IP
|
$434.29
|
|
|
Service Code
|
NDC 69344-102-33
|
| Hospital Charge Code |
1748065
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$104.23 |
| Max. Negotiated Rate |
$369.15 |
| Rate for Payer: Blue Shield of California Commercial |
$309.21
|
| Rate for Payer: Blue Shield of California EPN |
$222.36
|
| Rate for Payer: Cash Price |
$195.43
|
| Rate for Payer: Cigna of CA HMO |
$304.00
|
| Rate for Payer: Cigna of CA PPO |
$304.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$173.72
|
| Rate for Payer: Galaxy Health WC |
$369.15
|
| Rate for Payer: Global Benefits Group Commercial |
$260.57
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$289.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$165.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$104.23
|
| Rate for Payer: Multiplan Commercial |
$347.43
|
| Rate for Payer: Networks By Design Commercial |
$282.29
|
| Rate for Payer: Prime Health Services Commercial |
$369.15
|
|
|
INDOMETHACIN 50 MG RECTAL SUPPOSITORY [3901]
|
Facility
|
OP
|
$434.29
|
|
|
Service Code
|
NDC 69344-102-33
|
| Hospital Charge Code |
1748065
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$104.23 |
| Max. Negotiated Rate |
$369.15 |
| Rate for Payer: Aetna of CA HMO/PPO |
$284.85
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$369.15
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$238.86
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$238.86
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$258.75
|
| Rate for Payer: Blue Distinction Transplant |
$260.57
|
| Rate for Payer: Blue Shield of California Commercial |
$320.07
|
| Rate for Payer: Blue Shield of California EPN |
$253.63
|
| Rate for Payer: Cash Price |
$195.43
|
| Rate for Payer: Cigna of CA HMO |
$304.00
|
| Rate for Payer: Cigna of CA PPO |
$304.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$369.15
|
| Rate for Payer: Dignity Health Media |
$369.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$369.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$173.72
|
| Rate for Payer: EPIC Health Plan Transplant |
$173.72
|
| Rate for Payer: Galaxy Health WC |
$369.15
|
| Rate for Payer: Global Benefits Group Commercial |
$260.57
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$325.72
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$289.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$165.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$104.23
|
| Rate for Payer: Multiplan Commercial |
$347.43
|
| Rate for Payer: Networks By Design Commercial |
$282.29
|
| Rate for Payer: Prime Health Services Commercial |
$369.15
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$260.57
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$260.57
|
| Rate for Payer: United Healthcare All Other Commercial |
$217.14
|
| Rate for Payer: United Healthcare All Other HMO |
$217.14
|
| Rate for Payer: United Healthcare HMO Rider |
$217.14
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$217.14
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$369.15
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$369.15
|
| Rate for Payer: Vantage Medical Group Senior |
$369.15
|
|
|
INDOMETHACIN ER 75 MG CAPSULE,EXTENDED RELEASE [14628]
|
Facility
|
IP
|
$0.42
|
|
|
Service Code
|
NDC 68462-325-60
|
| Hospital Charge Code |
1710396
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.36 |
| Rate for Payer: Blue Shield of California Commercial |
$0.30
|
| Rate for Payer: Blue Shield of California EPN |
$0.22
|
| Rate for Payer: Cash Price |
$0.19
|
| 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 |
$0.17
|
| Rate for Payer: Galaxy Health WC |
$0.36
|
| Rate for Payer: Global Benefits Group Commercial |
$0.25
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.28
|
| 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 |
$0.34
|
| Rate for Payer: Networks By Design Commercial |
$0.27
|
| Rate for Payer: Prime Health Services Commercial |
$0.36
|
|
|
INDOMETHACIN ER 75 MG CAPSULE,EXTENDED RELEASE [14628]
|
Facility
|
OP
|
$0.42
|
|
|
Service Code
|
NDC 68462-325-60
|
| Hospital Charge Code |
1710396
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.36 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.28
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.36
|
| 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 |
$0.25
|
| Rate for Payer: Blue Distinction Transplant |
$0.25
|
| Rate for Payer: Blue Shield of California Commercial |
$0.31
|
| Rate for Payer: Blue Shield of California EPN |
$0.25
|
| Rate for Payer: Cash Price |
$0.19
|
| 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 |
$0.36
|
| Rate for Payer: Dignity Health Media |
$0.36
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.17
|
| Rate for Payer: Galaxy Health WC |
$0.36
|
| Rate for Payer: Global Benefits Group Commercial |
$0.25
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.28
|
| 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 |
$0.34
|
| Rate for Payer: Networks By Design Commercial |
$0.27
|
| Rate for Payer: Prime Health Services Commercial |
$0.36
|
| 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 |
$0.36
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.36
|
| Rate for Payer: Vantage Medical Group Senior |
$0.36
|
|
|
INFECTIONS OF UPPER RESPIRATORY TRACT
|
Facility
|
IP
|
$18,174.41
|
|
|
Service Code
|
APR-DRG 1134
|
| Min. Negotiated Rate |
$13,941.69 |
| Max. Negotiated Rate |
$18,174.41 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$13,941.69
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$18,174.41
|
|
|
INFECTIONS OF UPPER RESPIRATORY TRACT
|
Facility
|
IP
|
$11,112.49
|
|
|
Service Code
|
APR-DRG 1133
|
| Min. Negotiated Rate |
$8,524.45 |
| Max. Negotiated Rate |
$11,112.49 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$8,524.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$11,112.49
|
|
|
INFECTIONS OF UPPER RESPIRATORY TRACT
|
Facility
|
IP
|
$5,167.87
|
|
|
Service Code
|
APR-DRG 1131
|
| Min. Negotiated Rate |
$3,964.30 |
| Max. Negotiated Rate |
$5,167.87 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$3,964.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5,167.87
|
|
|
INFECTIONS OF UPPER RESPIRATORY TRACT
|
Facility
|
IP
|
$7,627.64
|
|
|
Service Code
|
APR-DRG 1132
|
| Min. Negotiated Rate |
$5,851.21 |
| Max. Negotiated Rate |
$7,627.64 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$5,851.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7,627.64
|
|
|
INFECTIOUS AND PARASITIC DISEASES INCLUDING HIV WITH O.R. PROCEDURE
|
Facility
|
IP
|
$38,157.76
|
|
|
Service Code
|
APR-DRG 7103
|
| Min. Negotiated Rate |
$29,271.02 |
| Max. Negotiated Rate |
$38,157.76 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$29,271.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$38,157.76
|
|
|
INFECTIOUS AND PARASITIC DISEASES INCLUDING HIV WITH O.R. PROCEDURE
|
Facility
|
IP
|
$70,372.68
|
|
|
Service Code
|
APR-DRG 7104
|
| Min. Negotiated Rate |
$53,983.25 |
| Max. Negotiated Rate |
$70,372.68 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$53,983.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$70,372.68
|
|
|
INFECTIOUS AND PARASITIC DISEASES INCLUDING HIV WITH O.R. PROCEDURE
|
Facility
|
IP
|
$23,289.08
|
|
|
Service Code
|
APR-DRG 7102
|
| Min. Negotiated Rate |
$17,865.18 |
| Max. Negotiated Rate |
$23,289.08 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$17,865.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$23,289.08
|
|
|
INFECTIOUS AND PARASITIC DISEASES INCLUDING HIV WITH O.R. PROCEDURE
|
Facility
|
IP
|
$16,099.48
|
|
|
Service Code
|
APR-DRG 7101
|
| Min. Negotiated Rate |
$12,350.00 |
| Max. Negotiated Rate |
$16,099.48 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$12,350.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$16,099.48
|
|
|
INFLAMMATORY BOWEL DISEASE
|
Facility
|
IP
|
$28,118.21
|
|
|
Service Code
|
APR-DRG 2454
|
| Min. Negotiated Rate |
$21,569.63 |
| Max. Negotiated Rate |
$28,118.21 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$21,569.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$28,118.21
|
|
|
INFLAMMATORY BOWEL DISEASE
|
Facility
|
IP
|
$11,217.14
|
|
|
Service Code
|
APR-DRG 2452
|
| Min. Negotiated Rate |
$8,604.73 |
| Max. Negotiated Rate |
$11,217.14 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$8,604.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$11,217.14
|
|
|
INFLAMMATORY BOWEL DISEASE
|
Facility
|
IP
|
$8,794.59
|
|
|
Service Code
|
APR-DRG 2451
|
| Min. Negotiated Rate |
$6,746.37 |
| Max. Negotiated Rate |
$8,794.59 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$6,746.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8,794.59
|
|
|
INFLAMMATORY BOWEL DISEASE
|
Facility
|
IP
|
$16,092.37
|
|
|
Service Code
|
APR-DRG 2453
|
| Min. Negotiated Rate |
$12,344.54 |
| Max. Negotiated Rate |
$16,092.37 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$12,344.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$16,092.37
|
|
|
INFLIXIMAB 100 MG INTRAVENOUS SOLUTION [23796]
|
Facility
|
IP
|
$570.00
|
|
|
Service Code
|
CPT J1745
|
| Hospital Charge Code |
1757347
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$136.80 |
| Max. Negotiated Rate |
$484.50 |
| Rate for Payer: Blue Shield of California Commercial |
$405.84
|
| Rate for Payer: Blue Shield of California EPN |
$291.84
|
| Rate for Payer: Cash Price |
$256.50
|
| Rate for Payer: Cigna of CA HMO |
$399.00
|
| Rate for Payer: Cigna of CA PPO |
$399.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$228.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$228.00
|
| Rate for Payer: Galaxy Health WC |
$484.50
|
| Rate for Payer: Global Benefits Group Commercial |
$342.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$380.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$217.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$136.80
|
| Rate for Payer: Multiplan Commercial |
$456.00
|
| Rate for Payer: Networks By Design Commercial |
$285.00
|
| Rate for Payer: Prime Health Services Commercial |
$484.50
|
| Rate for Payer: United Healthcare All Other Commercial |
$215.23
|
| Rate for Payer: United Healthcare All Other HMO |
$210.22
|
| Rate for Payer: United Healthcare HMO Rider |
$205.66
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$188.10
|
|
|
INFLIXIMAB 100 MG INTRAVENOUS SOLUTION [23796]
|
Facility
|
OP
|
$570.00
|
|
|
Service Code
|
CPT J1745
|
| Hospital Charge Code |
1757347
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$32.16 |
| Max. Negotiated Rate |
$484.50 |
| Rate for Payer: Aetna of CA HMO/PPO |
$202.26
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$40.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$35.38
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$35.38
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$126.69
|
| Rate for Payer: Blue Distinction Transplant |
$342.00
|
| Rate for Payer: Blue Shield of California Commercial |
$420.09
|
| Rate for Payer: Blue Shield of California EPN |
$140.14
|
| Rate for Payer: Cash Price |
$256.50
|
| Rate for Payer: Cash Price |
$256.50
|
| Rate for Payer: Cigna of CA HMO |
$399.00
|
| Rate for Payer: Cigna of CA PPO |
$399.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$48.24
|
| Rate for Payer: Dignity Health Media |
$32.16
|
| Rate for Payer: Dignity Health Medi-Cal |
$35.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$43.42
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$32.16
|
| Rate for Payer: EPIC Health Plan Transplant |
$32.16
|
| Rate for Payer: Galaxy Health WC |
$484.50
|
| Rate for Payer: Global Benefits Group Commercial |
$342.00
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$427.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$52.74
|
| Rate for Payer: Heritage Provider Network Transplant |
$52.74
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$52.10
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$52.10
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$32.16
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$380.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$69.58
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$32.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$136.80
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$40.52
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$43.10
|
| Rate for Payer: Multiplan Commercial |
$456.00
|
| Rate for Payer: Networks By Design Commercial |
$285.00
|
| Rate for Payer: Prime Health Services Commercial |
$484.50
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$342.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$342.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$285.00
|
| Rate for Payer: United Healthcare All Other HMO |
$285.00
|
| Rate for Payer: United Healthcare HMO Rider |
$285.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$285.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$48.24
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$35.38
|
| Rate for Payer: Vantage Medical Group Senior |
$32.16
|
|
|
INFLIXIMAB-ABDA 100 MG INTRAVENOUS SOLUTION [219233]
|
Facility
|
IP
|
$904.07
|
|
|
Service Code
|
NDC 78206-162-01
|
| Hospital Charge Code |
ERX219233
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$216.98 |
| Max. Negotiated Rate |
$768.46 |
| Rate for Payer: Blue Shield of California Commercial |
$643.70
|
| Rate for Payer: Blue Shield of California EPN |
$462.88
|
| Rate for Payer: Cash Price |
$406.83
|
| Rate for Payer: Cigna of CA HMO |
$632.85
|
| Rate for Payer: Cigna of CA PPO |
$632.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$361.63
|
| Rate for Payer: EPIC Health Plan Transplant |
$361.63
|
| Rate for Payer: Galaxy Health WC |
$768.46
|
| Rate for Payer: Global Benefits Group Commercial |
$542.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$603.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$344.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$216.98
|
| Rate for Payer: Multiplan Commercial |
$723.26
|
| Rate for Payer: Networks By Design Commercial |
$452.04
|
| Rate for Payer: Prime Health Services Commercial |
$768.46
|
| Rate for Payer: United Healthcare All Other Commercial |
$341.38
|
| Rate for Payer: United Healthcare All Other HMO |
$333.42
|
| Rate for Payer: United Healthcare HMO Rider |
$326.19
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$298.34
|
|
|
INFLIXIMAB-ABDA 100 MG INTRAVENOUS SOLUTION [219233]
|
Facility
|
OP
|
$904.07
|
|
|
Service Code
|
NDC 78206-162-01
|
| Hospital Charge Code |
ERX219233
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$216.98 |
| Max. Negotiated Rate |
$768.46 |
| Rate for Payer: Aetna of CA HMO/PPO |
$592.98
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$768.46
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$497.24
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$497.24
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$538.64
|
| Rate for Payer: Blue Distinction Transplant |
$542.44
|
| Rate for Payer: Blue Shield of California Commercial |
$666.30
|
| Rate for Payer: Blue Shield of California EPN |
$527.98
|
| Rate for Payer: Cash Price |
$406.83
|
| Rate for Payer: Cigna of CA HMO |
$632.85
|
| Rate for Payer: Cigna of CA PPO |
$632.85
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$768.46
|
| Rate for Payer: Dignity Health Media |
$768.46
|
| Rate for Payer: Dignity Health Medi-Cal |
$768.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$361.63
|
| Rate for Payer: EPIC Health Plan Transplant |
$361.63
|
| Rate for Payer: Galaxy Health WC |
$768.46
|
| Rate for Payer: Global Benefits Group Commercial |
$542.44
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$678.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$603.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$344.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$216.98
|
| Rate for Payer: Multiplan Commercial |
$723.26
|
| Rate for Payer: Networks By Design Commercial |
$452.04
|
| Rate for Payer: Prime Health Services Commercial |
$768.46
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$542.44
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$542.44
|
| Rate for Payer: United Healthcare All Other Commercial |
$452.04
|
| Rate for Payer: United Healthcare All Other HMO |
$452.04
|
| Rate for Payer: United Healthcare HMO Rider |
$452.04
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$452.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$768.46
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$768.46
|
| Rate for Payer: Vantage Medical Group Senior |
$768.46
|
|
|
INFLIXIMAB-ABDA 100 MG INTRAVENOUS SOLUTION [219233]
|
Facility
|
IP
|
$904.07
|
|
|
Service Code
|
NDC 78206-162-99
|
| Hospital Charge Code |
ERX219233
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$216.98 |
| Max. Negotiated Rate |
$768.46 |
| Rate for Payer: Blue Shield of California Commercial |
$643.70
|
| Rate for Payer: Blue Shield of California EPN |
$462.88
|
| Rate for Payer: Cash Price |
$406.83
|
| Rate for Payer: Cigna of CA HMO |
$632.85
|
| Rate for Payer: Cigna of CA PPO |
$632.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$361.63
|
| Rate for Payer: EPIC Health Plan Transplant |
$361.63
|
| Rate for Payer: Galaxy Health WC |
$768.46
|
| Rate for Payer: Global Benefits Group Commercial |
$542.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$603.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$344.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$216.98
|
| Rate for Payer: Multiplan Commercial |
$723.26
|
| Rate for Payer: Networks By Design Commercial |
$452.04
|
| Rate for Payer: Prime Health Services Commercial |
$768.46
|
| Rate for Payer: United Healthcare All Other Commercial |
$341.38
|
| Rate for Payer: United Healthcare All Other HMO |
$333.42
|
| Rate for Payer: United Healthcare HMO Rider |
$326.19
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$298.34
|
|
|
INFLIXIMAB-ABDA 100 MG INTRAVENOUS SOLUTION [219233]
|
Facility
|
OP
|
$904.07
|
|
|
Service Code
|
NDC 78206-162-99
|
| Hospital Charge Code |
ERX219233
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$216.98 |
| Max. Negotiated Rate |
$768.46 |
| Rate for Payer: Aetna of CA HMO/PPO |
$592.98
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$768.46
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$497.24
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$497.24
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$538.64
|
| Rate for Payer: Blue Distinction Transplant |
$542.44
|
| Rate for Payer: Blue Shield of California Commercial |
$666.30
|
| Rate for Payer: Blue Shield of California EPN |
$527.98
|
| Rate for Payer: Cash Price |
$406.83
|
| Rate for Payer: Cigna of CA HMO |
$632.85
|
| Rate for Payer: Cigna of CA PPO |
$632.85
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$768.46
|
| Rate for Payer: Dignity Health Media |
$768.46
|
| Rate for Payer: Dignity Health Medi-Cal |
$768.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$361.63
|
| Rate for Payer: EPIC Health Plan Transplant |
$361.63
|
| Rate for Payer: Galaxy Health WC |
$768.46
|
| Rate for Payer: Global Benefits Group Commercial |
$542.44
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$678.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$603.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$344.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$216.98
|
| Rate for Payer: Multiplan Commercial |
$723.26
|
| Rate for Payer: Networks By Design Commercial |
$452.04
|
| Rate for Payer: Prime Health Services Commercial |
$768.46
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$542.44
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$542.44
|
| Rate for Payer: United Healthcare All Other Commercial |
$452.04
|
| Rate for Payer: United Healthcare All Other HMO |
$452.04
|
| Rate for Payer: United Healthcare HMO Rider |
$452.04
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$452.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$768.46
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$768.46
|
| Rate for Payer: Vantage Medical Group Senior |
$768.46
|
|
