|
OMALIZUMAB 150 MG SUBCUTANEOUS SOLUTION [36151]
|
Facility
|
IP
|
$1,567.88
|
|
|
Service Code
|
CPT J2357
|
| Hospital Charge Code |
ERX36151
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$376.29 |
| Max. Negotiated Rate |
$1,332.70 |
| Rate for Payer: Blue Shield of California Commercial |
$1,116.33
|
| Rate for Payer: Blue Shield of California EPN |
$802.75
|
| Rate for Payer: Cash Price |
$705.55
|
| Rate for Payer: Cigna of CA HMO |
$1,097.52
|
| Rate for Payer: Cigna of CA PPO |
$1,097.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$627.15
|
| Rate for Payer: EPIC Health Plan Transplant |
$627.15
|
| Rate for Payer: Galaxy Health WC |
$1,332.70
|
| Rate for Payer: Global Benefits Group Commercial |
$940.73
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,045.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$597.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$376.29
|
| Rate for Payer: Multiplan Commercial |
$1,254.30
|
| Rate for Payer: Networks By Design Commercial |
$783.94
|
| Rate for Payer: Prime Health Services Commercial |
$1,332.70
|
| Rate for Payer: United Healthcare All Other Commercial |
$592.03
|
| Rate for Payer: United Healthcare All Other HMO |
$578.23
|
| Rate for Payer: United Healthcare HMO Rider |
$565.69
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$517.40
|
|
|
OMALIZUMAB 75 MG/0.5 ML SUBCUTANEOUS SYRINGE [223364]
|
Facility
|
OP
|
$1,567.87
|
|
|
Service Code
|
CPT J2357
|
| Hospital Charge Code |
NDG223364
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$33.71 |
| Max. Negotiated Rate |
$1,332.69 |
| Rate for Payer: Aetna of CA HMO/PPO |
$248.15
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$49.32
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$43.40
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$43.40
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$33.71
|
| Rate for Payer: Blue Distinction Transplant |
$940.72
|
| Rate for Payer: Blue Shield of California Commercial |
$1,155.52
|
| Rate for Payer: Blue Shield of California EPN |
$45.14
|
| Rate for Payer: Cash Price |
$705.54
|
| Rate for Payer: Cash Price |
$705.54
|
| Rate for Payer: Cigna of CA HMO |
$1,097.51
|
| Rate for Payer: Cigna of CA PPO |
$1,097.51
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$59.19
|
| Rate for Payer: Dignity Health Media |
$39.46
|
| Rate for Payer: Dignity Health Medi-Cal |
$43.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$53.27
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$39.46
|
| Rate for Payer: EPIC Health Plan Transplant |
$39.46
|
| Rate for Payer: Galaxy Health WC |
$1,332.69
|
| Rate for Payer: Global Benefits Group Commercial |
$940.72
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$1,175.90
|
| Rate for Payer: Heritage Provider Network Commercial |
$64.71
|
| Rate for Payer: Heritage Provider Network Transplant |
$64.71
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$63.92
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$63.92
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$39.46
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,045.77
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$83.45
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$39.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$376.29
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$49.72
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$52.88
|
| Rate for Payer: Multiplan Commercial |
$1,254.30
|
| Rate for Payer: Networks By Design Commercial |
$783.94
|
| Rate for Payer: Prime Health Services Commercial |
$1,332.69
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$940.72
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$940.72
|
| Rate for Payer: United Healthcare All Other Commercial |
$783.94
|
| Rate for Payer: United Healthcare All Other HMO |
$783.94
|
| Rate for Payer: United Healthcare HMO Rider |
$783.94
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$783.94
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$59.19
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$43.40
|
| Rate for Payer: Vantage Medical Group Senior |
$39.46
|
|
|
OMALIZUMAB 75 MG/0.5 ML SUBCUTANEOUS SYRINGE [223364]
|
Facility
|
IP
|
$1,567.87
|
|
|
Service Code
|
CPT J2357
|
| Hospital Charge Code |
NDG223364
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$376.29 |
| Max. Negotiated Rate |
$1,332.69 |
| Rate for Payer: Blue Shield of California Commercial |
$1,116.32
|
| Rate for Payer: Blue Shield of California EPN |
$802.75
|
| Rate for Payer: Cash Price |
$705.54
|
| Rate for Payer: Cigna of CA HMO |
$1,097.51
|
| Rate for Payer: Cigna of CA PPO |
$1,097.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$627.15
|
| Rate for Payer: EPIC Health Plan Transplant |
$627.15
|
| Rate for Payer: Galaxy Health WC |
$1,332.69
|
| Rate for Payer: Global Benefits Group Commercial |
$940.72
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,045.77
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$597.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$376.29
|
| Rate for Payer: Multiplan Commercial |
$1,254.30
|
| Rate for Payer: Networks By Design Commercial |
$783.94
|
| Rate for Payer: Prime Health Services Commercial |
$1,332.69
|
| Rate for Payer: United Healthcare All Other Commercial |
$592.03
|
| Rate for Payer: United Healthcare All Other HMO |
$578.23
|
| Rate for Payer: United Healthcare HMO Rider |
$565.69
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$517.40
|
|
|
OMEGA-3 ACID ETHYL ESTERS 1 GRAM CAPSULE [41822]
|
Facility
|
IP
|
$3.65
|
|
|
Service Code
|
NDC 60687-127-11
|
| Hospital Charge Code |
1712384
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.88 |
| Max. Negotiated Rate |
$3.10 |
| Rate for Payer: Blue Shield of California Commercial |
$2.60
|
| Rate for Payer: Blue Shield of California EPN |
$1.87
|
| Rate for Payer: Cash Price |
$1.64
|
| Rate for Payer: Cigna of CA HMO |
$2.56
|
| Rate for Payer: Cigna of CA PPO |
$2.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.46
|
| Rate for Payer: Galaxy Health WC |
$3.10
|
| Rate for Payer: Global Benefits Group Commercial |
$2.19
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.88
|
| Rate for Payer: Multiplan Commercial |
$2.92
|
| Rate for Payer: Networks By Design Commercial |
$2.37
|
| Rate for Payer: Prime Health Services Commercial |
$3.10
|
|
|
OMEGA-3 ACID ETHYL ESTERS 1 GRAM CAPSULE [41822]
|
Facility
|
IP
|
$0.97
|
|
|
Service Code
|
NDC 60505-3170-7
|
| Hospital Charge Code |
1712384
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$0.82 |
| Rate for Payer: Blue Shield of California Commercial |
$0.69
|
| Rate for Payer: Blue Shield of California EPN |
$0.50
|
| Rate for Payer: Cash Price |
$0.44
|
| Rate for Payer: Cigna of CA HMO |
$0.68
|
| Rate for Payer: Cigna of CA PPO |
$0.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.39
|
| Rate for Payer: Galaxy Health WC |
$0.82
|
| Rate for Payer: Global Benefits Group Commercial |
$0.58
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: Multiplan Commercial |
$0.78
|
| Rate for Payer: Networks By Design Commercial |
$0.63
|
| Rate for Payer: Prime Health Services Commercial |
$0.82
|
|
|
OMEGA-3 ACID ETHYL ESTERS 1 GRAM CAPSULE [41822]
|
Facility
|
OP
|
$0.97
|
|
|
Service Code
|
NDC 60505-3170-7
|
| Hospital Charge Code |
1712384
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$0.82 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.64
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.82
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.53
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.53
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.58
|
| Rate for Payer: Blue Distinction Transplant |
$0.58
|
| Rate for Payer: Blue Shield of California Commercial |
$0.71
|
| Rate for Payer: Blue Shield of California EPN |
$0.57
|
| Rate for Payer: Cash Price |
$0.44
|
| Rate for Payer: Cigna of CA HMO |
$0.68
|
| Rate for Payer: Cigna of CA PPO |
$0.68
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.82
|
| Rate for Payer: Dignity Health Media |
$0.82
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.39
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.39
|
| Rate for Payer: Galaxy Health WC |
$0.82
|
| Rate for Payer: Global Benefits Group Commercial |
$0.58
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.73
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: Multiplan Commercial |
$0.78
|
| Rate for Payer: Networks By Design Commercial |
$0.63
|
| Rate for Payer: Prime Health Services Commercial |
$0.82
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.58
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.58
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.49
|
| Rate for Payer: United Healthcare All Other HMO |
$0.49
|
| Rate for Payer: United Healthcare HMO Rider |
$0.49
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.49
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.82
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.82
|
| Rate for Payer: Vantage Medical Group Senior |
$0.82
|
|
|
OMEGA-3 ACID ETHYL ESTERS 1 GRAM CAPSULE [41822]
|
Facility
|
OP
|
$0.27
|
|
|
Service Code
|
NDC 64380-761-11
|
| Hospital Charge Code |
1712384
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.18
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.23
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.15
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.15
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.16
|
| Rate for Payer: Blue Distinction Transplant |
$0.16
|
| Rate for Payer: Blue Shield of California Commercial |
$0.20
|
| Rate for Payer: Blue Shield of California EPN |
$0.16
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cigna of CA HMO |
$0.19
|
| Rate for Payer: Cigna of CA PPO |
$0.19
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.23
|
| Rate for Payer: Dignity Health Media |
$0.23
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.11
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.11
|
| Rate for Payer: Galaxy Health WC |
$0.23
|
| Rate for Payer: Global Benefits Group Commercial |
$0.16
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.22
|
| Rate for Payer: Networks By Design Commercial |
$0.18
|
| Rate for Payer: Prime Health Services Commercial |
$0.23
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.16
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.16
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.14
|
| Rate for Payer: United Healthcare All Other HMO |
$0.14
|
| Rate for Payer: United Healthcare HMO Rider |
$0.14
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.14
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.23
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.23
|
| Rate for Payer: Vantage Medical Group Senior |
$0.23
|
|
|
OMEGA-3 ACID ETHYL ESTERS 1 GRAM CAPSULE [41822]
|
Facility
|
IP
|
$3.65
|
|
|
Service Code
|
NDC 60687-127-65
|
| Hospital Charge Code |
1712384
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.88 |
| Max. Negotiated Rate |
$3.10 |
| Rate for Payer: Blue Shield of California Commercial |
$2.60
|
| Rate for Payer: Blue Shield of California EPN |
$1.87
|
| Rate for Payer: Cash Price |
$1.64
|
| Rate for Payer: Cigna of CA HMO |
$2.56
|
| Rate for Payer: Cigna of CA PPO |
$2.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.46
|
| Rate for Payer: Galaxy Health WC |
$3.10
|
| Rate for Payer: Global Benefits Group Commercial |
$2.19
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.88
|
| Rate for Payer: Multiplan Commercial |
$2.92
|
| Rate for Payer: Networks By Design Commercial |
$2.37
|
| Rate for Payer: Prime Health Services Commercial |
$3.10
|
|
|
OMEGA-3 ACID ETHYL ESTERS 1 GRAM CAPSULE [41822]
|
Facility
|
OP
|
$3.65
|
|
|
Service Code
|
NDC 60687-127-11
|
| Hospital Charge Code |
1712384
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.88 |
| Max. Negotiated Rate |
$3.10 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2.39
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.10
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.01
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.17
|
| Rate for Payer: Blue Distinction Transplant |
$2.19
|
| Rate for Payer: Blue Shield of California Commercial |
$2.69
|
| Rate for Payer: Blue Shield of California EPN |
$2.13
|
| Rate for Payer: Cash Price |
$1.64
|
| Rate for Payer: Cigna of CA HMO |
$2.56
|
| Rate for Payer: Cigna of CA PPO |
$2.56
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.10
|
| Rate for Payer: Dignity Health Media |
$3.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.46
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.46
|
| Rate for Payer: Galaxy Health WC |
$3.10
|
| Rate for Payer: Global Benefits Group Commercial |
$2.19
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$2.74
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.88
|
| Rate for Payer: Multiplan Commercial |
$2.92
|
| Rate for Payer: Networks By Design Commercial |
$2.37
|
| Rate for Payer: Prime Health Services Commercial |
$3.10
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.19
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.19
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.82
|
| Rate for Payer: United Healthcare All Other HMO |
$1.82
|
| Rate for Payer: United Healthcare HMO Rider |
$1.82
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.82
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.10
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.10
|
| Rate for Payer: Vantage Medical Group Senior |
$3.10
|
|
|
OMEGA-3 ACID ETHYL ESTERS 1 GRAM CAPSULE [41822]
|
Facility
|
IP
|
$0.27
|
|
|
Service Code
|
NDC 64380-761-11
|
| Hospital Charge Code |
1712384
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Blue Shield of California Commercial |
$0.19
|
| Rate for Payer: Blue Shield of California EPN |
$0.14
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cigna of CA HMO |
$0.19
|
| Rate for Payer: Cigna of CA PPO |
$0.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.11
|
| Rate for Payer: Galaxy Health WC |
$0.23
|
| Rate for Payer: Global Benefits Group Commercial |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.22
|
| Rate for Payer: Networks By Design Commercial |
$0.18
|
| Rate for Payer: Prime Health Services Commercial |
$0.23
|
|
|
OMEGA-3 ACID ETHYL ESTERS 1 GRAM CAPSULE [41822]
|
Facility
|
OP
|
$3.65
|
|
|
Service Code
|
NDC 60687-127-65
|
| Hospital Charge Code |
1712384
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.88 |
| Max. Negotiated Rate |
$3.10 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2.39
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.10
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.01
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.17
|
| Rate for Payer: Blue Distinction Transplant |
$2.19
|
| Rate for Payer: Blue Shield of California Commercial |
$2.69
|
| Rate for Payer: Blue Shield of California EPN |
$2.13
|
| Rate for Payer: Cash Price |
$1.64
|
| Rate for Payer: Cigna of CA HMO |
$2.56
|
| Rate for Payer: Cigna of CA PPO |
$2.56
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.10
|
| Rate for Payer: Dignity Health Media |
$3.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.46
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.46
|
| Rate for Payer: Galaxy Health WC |
$3.10
|
| Rate for Payer: Global Benefits Group Commercial |
$2.19
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$2.74
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.88
|
| Rate for Payer: Multiplan Commercial |
$2.92
|
| Rate for Payer: Networks By Design Commercial |
$2.37
|
| Rate for Payer: Prime Health Services Commercial |
$3.10
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.19
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.19
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.82
|
| Rate for Payer: United Healthcare All Other HMO |
$1.82
|
| Rate for Payer: United Healthcare HMO Rider |
$1.82
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.82
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.10
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.10
|
| Rate for Payer: Vantage Medical Group Senior |
$3.10
|
|
|
OMEGA 3-DHA-EPA-FISH OIL 300 MG-1,000 MG CAPSULE [10774]
|
Facility
|
IP
|
$0.08
|
|
|
Service Code
|
NDC 1191710202
|
| Hospital Charge Code |
1712604
|
|
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
|
|
|
OMEGA 3-DHA-EPA-FISH OIL 300 MG-1,000 MG CAPSULE [10774]
|
Facility
|
OP
|
$0.08
|
|
|
Service Code
|
NDC 1191710202
|
| Hospital Charge Code |
1712604
|
|
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
|
|
|
OMEGA-3 FATTY ACIDS 1,000 MG CAPSULE [31828]
|
Facility
|
IP
|
$0.06
|
|
|
Service Code
|
NDC 1093933733
|
| Hospital Charge Code |
1712605
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Blue Shield of California Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California EPN |
$0.03
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna of CA HMO |
$0.04
|
| Rate for Payer: Cigna of CA PPO |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.05
|
| Rate for Payer: Global Benefits Group Commercial |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
| Rate for Payer: Networks By Design Commercial |
$0.04
|
| Rate for Payer: Prime Health Services Commercial |
$0.05
|
|
|
OMEGA-3 FATTY ACIDS 1,000 MG CAPSULE [31828]
|
Facility
|
OP
|
$0.06
|
|
|
Service Code
|
NDC 1093933733
|
| Hospital Charge Code |
1712605
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.05
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.03
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.04
|
| Rate for Payer: Blue Distinction Transplant |
$0.04
|
| Rate for Payer: Blue Shield of California Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California EPN |
$0.04
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna of CA HMO |
$0.04
|
| Rate for Payer: Cigna of CA PPO |
$0.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.05
|
| Rate for Payer: Dignity Health Media |
$0.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.05
|
| Rate for Payer: Global Benefits Group Commercial |
$0.04
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
| Rate for Payer: Networks By Design Commercial |
$0.04
|
| Rate for Payer: Prime Health Services Commercial |
$0.05
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.04
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.04
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.03
|
| Rate for Payer: United Healthcare All Other HMO |
$0.03
|
| Rate for Payer: United Healthcare HMO Rider |
$0.03
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.03
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.05
|
| Rate for Payer: Vantage Medical Group Senior |
$0.05
|
|
|
OMEPRAZOLE MAGNESIUM 20 MG TABLET,DELAYED RELEASE [36205]
|
Facility
|
IP
|
$0.86
|
|
|
Service Code
|
NDC 37000-459-02
|
| Hospital Charge Code |
ERX36205
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$0.73 |
| Rate for Payer: Blue Shield of California Commercial |
$0.61
|
| Rate for Payer: Blue Shield of California EPN |
$0.44
|
| Rate for Payer: Cash Price |
$0.39
|
| Rate for Payer: Cigna of CA HMO |
$0.60
|
| Rate for Payer: Cigna of CA PPO |
$0.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.34
|
| Rate for Payer: Galaxy Health WC |
$0.73
|
| Rate for Payer: Global Benefits Group Commercial |
$0.52
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.21
|
| Rate for Payer: Multiplan Commercial |
$0.69
|
| Rate for Payer: Networks By Design Commercial |
$0.56
|
| Rate for Payer: Prime Health Services Commercial |
$0.73
|
|
|
OMEPRAZOLE MAGNESIUM 20 MG TABLET,DELAYED RELEASE [36205]
|
Facility
|
OP
|
$0.86
|
|
|
Service Code
|
NDC 37000-459-02
|
| Hospital Charge Code |
ERX36205
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$0.73 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.56
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.73
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.47
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.47
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.51
|
| Rate for Payer: Blue Distinction Transplant |
$0.52
|
| Rate for Payer: Blue Shield of California Commercial |
$0.63
|
| Rate for Payer: Blue Shield of California EPN |
$0.50
|
| Rate for Payer: Cash Price |
$0.39
|
| Rate for Payer: Cigna of CA HMO |
$0.60
|
| Rate for Payer: Cigna of CA PPO |
$0.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.73
|
| Rate for Payer: Dignity Health Media |
$0.73
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.73
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.34
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.34
|
| Rate for Payer: Galaxy Health WC |
$0.73
|
| Rate for Payer: Global Benefits Group Commercial |
$0.52
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.65
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.21
|
| Rate for Payer: Multiplan Commercial |
$0.69
|
| Rate for Payer: Networks By Design Commercial |
$0.56
|
| Rate for Payer: Prime Health Services Commercial |
$0.73
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.52
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.52
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.43
|
| Rate for Payer: United Healthcare All Other HMO |
$0.43
|
| Rate for Payer: United Healthcare HMO Rider |
$0.43
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.43
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.73
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.73
|
| Rate for Payer: Vantage Medical Group Senior |
$0.73
|
|
|
ONABOTULINUMTOXINA 100 UNIT SOLUTION FOR INJECTION [32700]
|
Facility
|
OP
|
$760.80
|
|
|
Service Code
|
CPT J0585
|
| Hospital Charge Code |
1721073
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.33 |
| Max. Negotiated Rate |
$646.68 |
| Rate for Payer: Aetna of CA HMO/PPO |
$39.79
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$7.91
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6.96
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$6.96
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9.39
|
| Rate for Payer: Blue Distinction Transplant |
$456.48
|
| Rate for Payer: Blue Shield of California Commercial |
$560.71
|
| Rate for Payer: Blue Shield of California EPN |
$7.21
|
| Rate for Payer: Cash Price |
$342.36
|
| Rate for Payer: Cash Price |
$342.36
|
| Rate for Payer: Cigna of CA HMO |
$532.56
|
| Rate for Payer: Cigna of CA PPO |
$532.56
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.49
|
| Rate for Payer: Dignity Health Media |
$6.33
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.96
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.54
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$6.33
|
| Rate for Payer: EPIC Health Plan Transplant |
$6.33
|
| Rate for Payer: Galaxy Health WC |
$646.68
|
| Rate for Payer: Global Benefits Group Commercial |
$456.48
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$570.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.38
|
| Rate for Payer: Heritage Provider Network Transplant |
$10.38
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$10.25
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$10.25
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$6.33
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$507.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$20.50
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$6.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$182.59
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$7.97
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$8.48
|
| Rate for Payer: Multiplan Commercial |
$608.64
|
| Rate for Payer: Networks By Design Commercial |
$380.40
|
| Rate for Payer: Prime Health Services Commercial |
$646.68
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$456.48
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$456.48
|
| Rate for Payer: United Healthcare All Other Commercial |
$380.40
|
| Rate for Payer: United Healthcare All Other HMO |
$380.40
|
| Rate for Payer: United Healthcare HMO Rider |
$380.40
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$380.40
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$9.49
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.96
|
| Rate for Payer: Vantage Medical Group Senior |
$6.33
|
|
|
ONABOTULINUMTOXINA 100 UNIT SOLUTION FOR INJECTION [32700]
|
Facility
|
IP
|
$760.80
|
|
|
Service Code
|
CPT J0585
|
| Hospital Charge Code |
1721073
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$182.59 |
| Max. Negotiated Rate |
$646.68 |
| Rate for Payer: Blue Shield of California Commercial |
$541.69
|
| Rate for Payer: Blue Shield of California EPN |
$389.53
|
| Rate for Payer: Cash Price |
$342.36
|
| Rate for Payer: Cigna of CA HMO |
$532.56
|
| Rate for Payer: Cigna of CA PPO |
$532.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$304.32
|
| Rate for Payer: EPIC Health Plan Transplant |
$304.32
|
| Rate for Payer: Galaxy Health WC |
$646.68
|
| Rate for Payer: Global Benefits Group Commercial |
$456.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$507.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$289.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$182.59
|
| Rate for Payer: Multiplan Commercial |
$608.64
|
| Rate for Payer: Networks By Design Commercial |
$380.40
|
| Rate for Payer: Prime Health Services Commercial |
$646.68
|
| Rate for Payer: United Healthcare All Other Commercial |
$287.28
|
| Rate for Payer: United Healthcare All Other HMO |
$280.58
|
| Rate for Payer: United Healthcare HMO Rider |
$274.50
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$251.06
|
|
|
ONABOTULINUMTOXINA (COSMETIC) 50 UNIT INTRAMUSCULAR SOLUTION [95794]
|
Facility
|
IP
|
$420.00
|
|
|
Service Code
|
NDC 0023-3919-50
|
| Hospital Charge Code |
ERX95794
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$100.80 |
| Max. Negotiated Rate |
$357.00 |
| Rate for Payer: Blue Shield of California Commercial |
$299.04
|
| Rate for Payer: Blue Shield of California EPN |
$215.04
|
| Rate for Payer: Cash Price |
$189.00
|
| Rate for Payer: Cigna of CA HMO |
$294.00
|
| Rate for Payer: Cigna of CA PPO |
$294.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$168.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$168.00
|
| Rate for Payer: Galaxy Health WC |
$357.00
|
| Rate for Payer: Global Benefits Group Commercial |
$252.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$280.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$160.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$100.80
|
| Rate for Payer: Multiplan Commercial |
$336.00
|
| Rate for Payer: Networks By Design Commercial |
$210.00
|
| Rate for Payer: Prime Health Services Commercial |
$357.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$158.59
|
| Rate for Payer: United Healthcare All Other HMO |
$154.90
|
| Rate for Payer: United Healthcare HMO Rider |
$151.54
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$138.60
|
|
|
ONABOTULINUMTOXINA (COSMETIC) 50 UNIT INTRAMUSCULAR SOLUTION [95794]
|
Facility
|
OP
|
$420.00
|
|
|
Service Code
|
NDC 0023-3919-50
|
| Hospital Charge Code |
ERX95794
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$100.80 |
| Max. Negotiated Rate |
$357.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$275.48
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$357.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$231.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$231.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$250.24
|
| Rate for Payer: Blue Distinction Transplant |
$252.00
|
| Rate for Payer: Blue Shield of California Commercial |
$309.54
|
| Rate for Payer: Blue Shield of California EPN |
$245.28
|
| Rate for Payer: Cash Price |
$189.00
|
| Rate for Payer: Cigna of CA HMO |
$294.00
|
| Rate for Payer: Cigna of CA PPO |
$294.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$357.00
|
| Rate for Payer: Dignity Health Media |
$357.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$357.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$168.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$168.00
|
| Rate for Payer: Galaxy Health WC |
$357.00
|
| Rate for Payer: Global Benefits Group Commercial |
$252.00
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$315.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$280.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$160.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$100.80
|
| Rate for Payer: Multiplan Commercial |
$336.00
|
| Rate for Payer: Networks By Design Commercial |
$210.00
|
| Rate for Payer: Prime Health Services Commercial |
$357.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$252.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$252.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$210.00
|
| Rate for Payer: United Healthcare All Other HMO |
$210.00
|
| Rate for Payer: United Healthcare HMO Rider |
$210.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$210.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$357.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$357.00
|
| Rate for Payer: Vantage Medical Group Senior |
$357.00
|
|
|
ONASEMNOGENE ABEPARVOVEC-XIOI 2 X 10EXP13 VG/ML IV SUSPENSION,KIT [224879]
|
Facility
|
OP
|
$35,465.93
|
|
|
Service Code
|
CPT J3399
|
| Hospital Charge Code |
ERX224879
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8,511.82 |
| Max. Negotiated Rate |
$4,952,363.19 |
| Rate for Payer: Aetna of CA HMO/PPO |
$23,262.10
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,774,667.06
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3,321,707.02
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3,321,707.02
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,529,412.00
|
| Rate for Payer: Blue Distinction Transplant |
$21,279.56
|
| Rate for Payer: Blue Shield of California Commercial |
$26,138.39
|
| Rate for Payer: Blue Shield of California EPN |
$2,550,000.00
|
| Rate for Payer: Cash Price |
$15,959.67
|
| Rate for Payer: Cash Price |
$15,959.67
|
| Rate for Payer: Cigna of CA HMO |
$24,826.15
|
| Rate for Payer: Cigna of CA PPO |
$24,826.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4,529,600.48
|
| Rate for Payer: Dignity Health Media |
$3,019,733.65
|
| Rate for Payer: Dignity Health Medi-Cal |
$3,321,707.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$4,076,640.43
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$3,019,733.65
|
| Rate for Payer: EPIC Health Plan Transplant |
$3,019,733.65
|
| Rate for Payer: Galaxy Health WC |
$30,146.04
|
| Rate for Payer: Global Benefits Group Commercial |
$21,279.56
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$26,599.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$4,952,363.19
|
| Rate for Payer: Heritage Provider Network Transplant |
$4,952,363.19
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$4,891,968.51
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$4,891,968.51
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$3,019,733.65
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$23,655.78
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3,019,733.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8,511.82
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3,804,864.40
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4,046,443.09
|
| Rate for Payer: Multiplan Commercial |
$28,372.74
|
| Rate for Payer: Networks By Design Commercial |
$17,732.96
|
| Rate for Payer: Prime Health Services Commercial |
$30,146.04
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$21,279.56
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$21,279.56
|
| Rate for Payer: United Healthcare All Other Commercial |
$17,732.96
|
| Rate for Payer: United Healthcare All Other HMO |
$17,732.96
|
| Rate for Payer: United Healthcare HMO Rider |
$17,732.96
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$17,732.96
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4,529,600.48
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3,321,707.02
|
| Rate for Payer: Vantage Medical Group Senior |
$3,019,733.65
|
|
|
ONASEMNOGENE ABEPARVOVEC-XIOI 2 X 10EXP13 VG/ML IV SUSPENSION,KIT [224879]
|
Facility
|
IP
|
$35,465.93
|
|
|
Service Code
|
CPT J3399
|
| Hospital Charge Code |
ERX224879
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8,511.82 |
| Max. Negotiated Rate |
$30,146.04 |
| Rate for Payer: Blue Shield of California Commercial |
$25,251.74
|
| Rate for Payer: Blue Shield of California EPN |
$18,158.56
|
| Rate for Payer: Cash Price |
$15,959.67
|
| Rate for Payer: Cigna of CA HMO |
$24,826.15
|
| Rate for Payer: Cigna of CA PPO |
$24,826.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$14,186.37
|
| Rate for Payer: EPIC Health Plan Transplant |
$14,186.37
|
| Rate for Payer: Galaxy Health WC |
$30,146.04
|
| Rate for Payer: Global Benefits Group Commercial |
$21,279.56
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$23,655.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$13,512.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8,511.82
|
| Rate for Payer: Multiplan Commercial |
$28,372.74
|
| Rate for Payer: Networks By Design Commercial |
$17,732.96
|
| Rate for Payer: Prime Health Services Commercial |
$30,146.04
|
| Rate for Payer: United Healthcare All Other Commercial |
$13,391.94
|
| Rate for Payer: United Healthcare All Other HMO |
$13,079.83
|
| Rate for Payer: United Healthcare HMO Rider |
$12,796.11
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$11,703.76
|
|
|
ONDANSETRON 4 MG DISINTEGRATING TABLET [27697]
|
Facility
|
IP
|
$0.73
|
|
|
Service Code
|
NDC 62756-240-64
|
| Hospital Charge Code |
1711782
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.62 |
| Rate for Payer: Blue Shield of California Commercial |
$0.52
|
| Rate for Payer: Blue Shield of California EPN |
$0.37
|
| Rate for Payer: Cash Price |
$0.33
|
| Rate for Payer: Cigna of CA HMO |
$0.51
|
| Rate for Payer: Cigna of CA PPO |
$0.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.29
|
| Rate for Payer: Galaxy Health WC |
$0.62
|
| Rate for Payer: Global Benefits Group Commercial |
$0.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.58
|
| Rate for Payer: Networks By Design Commercial |
$0.47
|
| Rate for Payer: Prime Health Services Commercial |
$0.62
|
|
|
ONDANSETRON 4 MG DISINTEGRATING TABLET [27697]
|
Facility
|
OP
|
$0.55
|
|
|
Service Code
|
NDC 68462-157-40
|
| Hospital Charge Code |
1711782
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.47 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.36
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.47
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.30
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.30
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.33
|
| Rate for Payer: Blue Distinction Transplant |
$0.33
|
| Rate for Payer: Blue Shield of California Commercial |
$0.41
|
| Rate for Payer: Blue Shield of California EPN |
$0.32
|
| Rate for Payer: Cash Price |
$0.25
|
| Rate for Payer: Cigna of CA HMO |
$0.39
|
| Rate for Payer: Cigna of CA PPO |
$0.39
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.47
|
| Rate for Payer: Dignity Health Media |
$0.47
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.22
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.22
|
| Rate for Payer: Galaxy Health WC |
$0.47
|
| Rate for Payer: Global Benefits Group Commercial |
$0.33
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.41
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.44
|
| Rate for Payer: Networks By Design Commercial |
$0.36
|
| Rate for Payer: Prime Health Services Commercial |
$0.47
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.33
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.33
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.28
|
| Rate for Payer: United Healthcare All Other HMO |
$0.28
|
| Rate for Payer: United Healthcare HMO Rider |
$0.28
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.28
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.47
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.47
|
| Rate for Payer: Vantage Medical Group Senior |
$0.47
|
|
