|
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 |
$32.33 |
| Max. Negotiated Rate |
$145.48 |
| Rate for Payer: Aetna of CA HMO/PPO |
$98.16
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$137.39
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$88.90
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$88.90
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$78.27
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$95.50
|
| Rate for Payer: BCBS Transplant Transplant |
$96.98
|
| Rate for Payer: Blue Shield of California Commercial |
$101.67
|
| Rate for Payer: Blue Shield of California EPN |
$79.04
|
| Rate for Payer: Cash Price |
$72.74
|
| Rate for Payer: Central Health Plan Commercial |
$129.31
|
| 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: 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 Management Network EPO/PPO |
$145.48
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$121.23
|
| Rate for Payer: IEHP medi-cal |
$56.57
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$107.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$32.33
|
| Rate for Payer: Multiplan Commercial |
$121.23
|
| Rate for Payer: Networks By Design Commercial |
$105.07
|
| Rate for Payer: Prime Health Services Commercial |
$137.39
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$96.98
|
| Rate for Payer: Riverside University Health MISP |
$64.66
|
| 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 Medi-Cal |
$137.39
|
| Rate for Payer: Vantage Medical Group Senior |
$137.39
|
|
|
ILOPROST 20 MCG/ML SOLUTION FOR NEBULIZATION [99773]
|
Facility
OP
|
$161.64
|
|
|
Service Code
|
NDC 66215-303-30
|
| Hospital Charge Code |
1744134
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$32.33 |
| Max. Negotiated Rate |
$145.48 |
| Rate for Payer: Aetna of CA HMO/PPO |
$98.16
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$137.39
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$88.90
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$88.90
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$78.27
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$95.50
|
| Rate for Payer: BCBS Transplant Transplant |
$96.98
|
| Rate for Payer: Blue Shield of California Commercial |
$101.67
|
| Rate for Payer: Blue Shield of California EPN |
$79.04
|
| Rate for Payer: Cash Price |
$72.74
|
| Rate for Payer: Central Health Plan Commercial |
$129.31
|
| 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: 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 Management Network EPO/PPO |
$145.48
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$121.23
|
| Rate for Payer: IEHP medi-cal |
$56.57
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$107.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$32.33
|
| Rate for Payer: Multiplan Commercial |
$121.23
|
| Rate for Payer: Networks By Design Commercial |
$105.07
|
| Rate for Payer: Prime Health Services Commercial |
$137.39
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$96.98
|
| Rate for Payer: Riverside University Health MISP |
$64.66
|
| 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 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 66215-303-30
|
| Hospital Charge Code |
1744134
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$32.33 |
| Max. Negotiated Rate |
$145.48 |
| Rate for Payer: Blue Shield of California Commercial |
$121.23
|
| Rate for Payer: Blue Shield of California EPN |
$86.32
|
| Rate for Payer: Cash Price |
$72.74
|
| Rate for Payer: Central Health Plan Commercial |
$129.31
|
| 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: Health Management Network EPO/PPO |
$145.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$107.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$32.33
|
| Rate for Payer: Multiplan Commercial |
$121.23
|
| 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
IP
|
$161.64
|
|
|
Service Code
|
NDC 66215-303-00
|
| Hospital Charge Code |
1744134
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$32.33 |
| Max. Negotiated Rate |
$145.48 |
| Rate for Payer: Blue Shield of California Commercial |
$121.23
|
| Rate for Payer: Blue Shield of California EPN |
$86.32
|
| Rate for Payer: Cash Price |
$72.74
|
| Rate for Payer: Central Health Plan Commercial |
$129.31
|
| 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: Health Management Network EPO/PPO |
$145.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$107.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$32.33
|
| Rate for Payer: Multiplan Commercial |
$121.23
|
| Rate for Payer: Networks By Design Commercial |
$105.07
|
| Rate for Payer: Prime Health Services Commercial |
$137.39
|
|
|
IMATINIB 100 MG TABLET [32979]
|
Facility
OP
|
$1.47
|
|
|
Service Code
|
CPT S0088
|
| Hospital Charge Code |
1711843
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$136.05 |
| Rate for Payer: Aetna of CA HMO/PPO |
$19.08
|
| Rate for Payer: Aetna of CA HMO/PPO |
$19.08
|
| Rate for Payer: Aetna of CA HMO/PPO |
$19.08
|
| Rate for Payer: Aetna of CA HMO/PPO |
$19.08
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.25
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3.87
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$45.56
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.67
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.50
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.81
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.08
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$29.48
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.81
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.50
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$29.48
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.08
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$124.26
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$124.26
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$124.26
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$124.26
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$136.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$136.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$136.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$136.05
|
| Rate for Payer: BCBS Transplant Transplant |
$32.16
|
| Rate for Payer: BCBS Transplant Transplant |
$0.88
|
| Rate for Payer: BCBS Transplant Transplant |
$2.73
|
| Rate for Payer: BCBS Transplant Transplant |
$1.18
|
| Rate for Payer: Blue Shield of California Commercial |
$1.24
|
| Rate for Payer: Blue Shield of California Commercial |
$2.86
|
| Rate for Payer: Blue Shield of California Commercial |
$33.71
|
| Rate for Payer: Blue Shield of California Commercial |
$0.92
|
| Rate for Payer: Blue Shield of California EPN |
$2.22
|
| Rate for Payer: Blue Shield of California EPN |
$0.72
|
| Rate for Payer: Blue Shield of California EPN |
$26.21
|
| Rate for Payer: Blue Shield of California EPN |
$0.96
|
| Rate for Payer: Cash Price |
$0.66
|
| Rate for Payer: Cash Price |
$0.89
|
| Rate for Payer: Cash Price |
$2.05
|
| Rate for Payer: Cash Price |
$24.12
|
| Rate for Payer: Cash Price |
$0.89
|
| Rate for Payer: Cash Price |
$24.12
|
| Rate for Payer: Cash Price |
$2.05
|
| Rate for Payer: Cash Price |
$0.66
|
| Rate for Payer: Central Health Plan Commercial |
$42.88
|
| Rate for Payer: Central Health Plan Commercial |
$3.64
|
| Rate for Payer: Central Health Plan Commercial |
$1.58
|
| Rate for Payer: Central Health Plan Commercial |
$1.18
|
| Rate for Payer: Cigna of CA HMO |
$1.03
|
| Rate for Payer: Cigna of CA HMO |
$3.18
|
| Rate for Payer: Cigna of CA HMO |
$37.52
|
| Rate for Payer: Cigna of CA HMO |
$1.38
|
| 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: Cigna of CA PPO |
$37.52
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.67
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.87
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$45.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.82
|
| 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 Transplant |
$0.79
|
| Rate for Payer: EPIC Health Plan Transplant |
$21.44
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.82
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.59
|
| 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 |
$0.88
|
| Rate for Payer: Global Benefits Group Commercial |
$1.18
|
| Rate for Payer: Global Benefits Group Commercial |
$32.16
|
| Rate for Payer: Global Benefits Group Commercial |
$2.73
|
| Rate for Payer: Health Management Network EPO/PPO |
$4.10
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.32
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.77
|
| Rate for Payer: Health Management Network EPO/PPO |
$48.24
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1.48
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$40.20
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1.10
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$3.41
|
| Rate for Payer: IEHP medi-cal |
$1.59
|
| Rate for Payer: IEHP medi-cal |
$0.69
|
| Rate for Payer: IEHP medi-cal |
$18.76
|
| Rate for Payer: IEHP medi-cal |
$0.51
|
| 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 |
$0.98
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$35.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Multiplan Commercial |
$1.10
|
| Rate for Payer: Multiplan Commercial |
$3.41
|
| Rate for Payer: Multiplan Commercial |
$40.20
|
| Rate for Payer: Multiplan Commercial |
$1.48
|
| Rate for Payer: Networks By Design Commercial |
$1.28
|
| Rate for Payer: Networks By Design Commercial |
$0.96
|
| Rate for Payer: Networks By Design Commercial |
$34.84
|
| Rate for Payer: Networks By Design Commercial |
$2.96
|
| Rate for Payer: Prime Health Services Commercial |
$45.56
|
| 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 |
$1.25
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.88
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$32.16
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$1.18
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$2.73
|
| Rate for Payer: Riverside University Health MISP |
$0.79
|
| Rate for Payer: Riverside University Health MISP |
$1.82
|
| Rate for Payer: Riverside University Health MISP |
$21.44
|
| Rate for Payer: Riverside University Health MISP |
$0.59
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.18
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.73
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$32.16
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.88
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.88
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.73
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$32.16
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.18
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.99
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.28
|
| 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 HMO |
$26.80
|
| Rate for Payer: United Healthcare All Other HMO |
$0.99
|
| Rate for Payer: United Healthcare All Other HMO |
$0.74
|
| Rate for Payer: United Healthcare All Other HMO |
$2.28
|
| Rate for Payer: United Healthcare HMO Rider |
$0.99
|
| 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 |
$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: United Healthcare Select/Navigate/Core |
$26.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.87
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.67
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$45.56
|
| Rate for Payer: Vantage Medical Group Senior |
$1.67
|
| Rate for Payer: Vantage Medical Group Senior |
$3.87
|
| Rate for Payer: Vantage Medical Group Senior |
$1.25
|
| Rate for Payer: Vantage Medical Group Senior |
$45.56
|
|
|
IMATINIB 100 MG TABLET [32979]
|
Facility
IP
|
$1.47
|
|
|
Service Code
|
CPT S0088
|
| Hospital Charge Code |
1711843
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$1.32 |
| Rate for Payer: Blue Shield of California Commercial |
$1.10
|
| Rate for Payer: Blue Shield of California Commercial |
$40.20
|
| Rate for Payer: Blue Shield of California Commercial |
$1.48
|
| Rate for Payer: Blue Shield of California Commercial |
$3.41
|
| Rate for Payer: Blue Shield of California EPN |
$1.05
|
| Rate for Payer: Blue Shield of California EPN |
$2.43
|
| Rate for Payer: Blue Shield of California EPN |
$0.78
|
| Rate for Payer: Blue Shield of California EPN |
$28.62
|
| Rate for Payer: Cash Price |
$2.05
|
| Rate for Payer: Cash Price |
$0.66
|
| Rate for Payer: Cash Price |
$24.12
|
| Rate for Payer: Cash Price |
$0.89
|
| Rate for Payer: Central Health Plan Commercial |
$42.88
|
| Rate for Payer: Central Health Plan Commercial |
$1.18
|
| Rate for Payer: Central Health Plan Commercial |
$3.64
|
| Rate for Payer: Central Health Plan Commercial |
$1.58
|
| Rate for Payer: Cigna of CA HMO |
$3.18
|
| 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 |
$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: Cigna of CA PPO |
$37.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$21.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.79
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.82
|
| Rate for Payer: Galaxy Health WC |
$3.87
|
| Rate for Payer: Galaxy Health WC |
$1.67
|
| Rate for Payer: Galaxy Health WC |
$1.25
|
| Rate for Payer: Galaxy Health WC |
$45.56
|
| Rate for Payer: Global Benefits Group Commercial |
$32.16
|
| 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: Health Management Network EPO/PPO |
$1.77
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.32
|
| Rate for Payer: Health Management Network EPO/PPO |
$48.24
|
| Rate for Payer: Health Management Network EPO/PPO |
$4.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.31
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.98
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$35.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.72
|
| Rate for Payer: Multiplan Commercial |
$3.41
|
| Rate for Payer: Multiplan Commercial |
$1.10
|
| Rate for Payer: Multiplan Commercial |
$40.20
|
| Rate for Payer: Multiplan Commercial |
$1.48
|
| 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 |
$1.28
|
| Rate for Payer: Networks By Design Commercial |
$34.84
|
| Rate for Payer: Prime Health Services Commercial |
$1.67
|
| Rate for Payer: Prime Health Services Commercial |
$45.56
|
| Rate for Payer: Prime Health Services Commercial |
$1.25
|
| Rate for Payer: Prime Health Services Commercial |
$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 |
$3.28 |
| Max. Negotiated Rate |
$136.05 |
| Rate for Payer: Aetna of CA HMO/PPO |
$19.08
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$13.92
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$9.01
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$9.01
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$124.26
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$136.05
|
| Rate for Payer: BCBS Transplant Transplant |
$9.83
|
| Rate for Payer: Blue Shield of California Commercial |
$10.30
|
| Rate for Payer: Blue Shield of California EPN |
$8.01
|
| Rate for Payer: Cash Price |
$7.37
|
| Rate for Payer: Cash Price |
$7.37
|
| Rate for Payer: Central Health Plan Commercial |
$13.10
|
| 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: 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 Management Network EPO/PPO |
$14.74
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$12.28
|
| Rate for Payer: IEHP medi-cal |
$5.73
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$10.93
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.28
|
| Rate for Payer: Multiplan Commercial |
$12.28
|
| Rate for Payer: Networks By Design Commercial |
$10.65
|
| Rate for Payer: Prime Health Services Commercial |
$13.92
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$9.83
|
| Rate for Payer: Riverside University Health MISP |
$6.55
|
| 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 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 |
$3.28 |
| Max. Negotiated Rate |
$14.74 |
| Rate for Payer: Blue Shield of California Commercial |
$12.28
|
| Rate for Payer: Blue Shield of California EPN |
$8.75
|
| Rate for Payer: Cash Price |
$7.37
|
| Rate for Payer: Central Health Plan Commercial |
$13.10
|
| 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: Health Management Network EPO/PPO |
$14.74
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$10.93
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.28
|
| Rate for Payer: Multiplan Commercial |
$12.28
|
| 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 |
$3.60 |
| Max. Negotiated Rate |
$16.19 |
| Rate for Payer: Blue Shield of California Commercial |
$13.49
|
| Rate for Payer: Blue Shield of California EPN |
$9.61
|
| Rate for Payer: Cash Price |
$8.10
|
| Rate for Payer: Central Health Plan Commercial |
$14.39
|
| 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: Health Management Network EPO/PPO |
$16.19
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$12.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.60
|
| Rate for Payer: Multiplan Commercial |
$13.49
|
| Rate for Payer: Networks By Design Commercial |
$9.00
|
| Rate for Payer: Prime Health Services Commercial |
$15.29
|
|
|
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 |
$3.60 |
| Max. Negotiated Rate |
$50.19 |
| Rate for Payer: Aetna of CA HMO/PPO |
$50.19
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$15.29
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$9.89
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$9.89
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$28.09
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$30.76
|
| Rate for Payer: BCBS Transplant Transplant |
$10.79
|
| Rate for Payer: Blue Shield of California Commercial |
$11.62
|
| 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: Central Health Plan Commercial |
$14.39
|
| 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: 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 Management Network EPO/PPO |
$16.19
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$13.49
|
| Rate for Payer: IEHP medi-cal |
$6.91
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$12.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.60
|
| Rate for Payer: Multiplan Commercial |
$13.49
|
| Rate for Payer: Networks By Design Commercial |
$9.00
|
| Rate for Payer: Prime Health Services Commercial |
$15.29
|
| Rate for Payer: Riverside University Health MISP |
$7.20
|
| 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 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 |
$6.91 |
| Max. Negotiated Rate |
$50.19 |
| Rate for Payer: Aetna of CA HMO/PPO |
$50.19
|
| Rate for Payer: Aetna of CA HMO/PPO |
$50.19
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$30.58
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$27.90
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$18.05
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$19.79
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$18.05
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$19.79
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$28.09
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$28.09
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$30.76
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$30.76
|
| Rate for Payer: BCBS Transplant Transplant |
$21.59
|
| Rate for Payer: BCBS Transplant Transplant |
$19.69
|
| Rate for Payer: Blue Shield of California Commercial |
$11.62
|
| Rate for Payer: Blue Shield of California Commercial |
$11.62
|
| 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 |
$16.19
|
| Rate for Payer: Cash Price |
$14.77
|
| Rate for Payer: Cash Price |
$16.19
|
| Rate for Payer: Cash Price |
$14.77
|
| Rate for Payer: Central Health Plan Commercial |
$26.26
|
| Rate for Payer: Central Health Plan Commercial |
$28.78
|
| 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 |
$22.97
|
| Rate for Payer: Cigna of CA PPO |
$25.19
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$27.90
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$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 |
$21.59
|
| Rate for Payer: Global Benefits Group Commercial |
$19.69
|
| Rate for Payer: Health Management Network EPO/PPO |
$32.38
|
| Rate for Payer: Health Management Network EPO/PPO |
$29.54
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$24.62
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$26.98
|
| Rate for Payer: IEHP medi-cal |
$6.91
|
| Rate for Payer: IEHP medi-cal |
$6.91
|
| 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: LLUH Dept of Risk Management WC |
$6.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.20
|
| Rate for Payer: Multiplan Commercial |
$26.98
|
| Rate for Payer: Multiplan Commercial |
$24.62
|
| 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: Riverside University Health MISP |
$13.13
|
| Rate for Payer: Riverside University Health MISP |
$14.39
|
| 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 |
$16.41
|
| Rate for Payer: United Healthcare HMO Rider |
$17.99
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$17.99
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$16.41
|
| 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 |
$27.90
|
| Rate for Payer: Vantage Medical Group Senior |
$30.58
|
|
|
IMIPENEM-CILASTATIN 500 MG INTRAVENOUS SOLUTION [9603]
|
Facility
IP
|
$35.98
|
|
|
Service Code
|
CPT J0743
|
| Hospital Charge Code |
1753116
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.20 |
| Max. Negotiated Rate |
$32.38 |
| Rate for Payer: Blue Shield of California Commercial |
$26.98
|
| Rate for Payer: Blue Shield of California Commercial |
$24.62
|
| Rate for Payer: Blue Shield of California EPN |
$17.53
|
| Rate for Payer: Blue Shield of California EPN |
$19.21
|
| Rate for Payer: Cash Price |
$16.19
|
| Rate for Payer: Cash Price |
$14.77
|
| Rate for Payer: Central Health Plan Commercial |
$26.26
|
| Rate for Payer: Central Health Plan Commercial |
$28.78
|
| 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 |
$22.97
|
| Rate for Payer: Cigna of CA PPO |
$25.19
|
| 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 |
$14.39
|
| Rate for Payer: EPIC Health Plan Transplant |
$13.13
|
| 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 Management Network EPO/PPO |
$29.54
|
| Rate for Payer: Health Management Network EPO/PPO |
$32.38
|
| 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: LLUH Dept of Risk Management WC |
$6.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.20
|
| Rate for Payer: Multiplan Commercial |
$26.98
|
| Rate for Payer: Multiplan Commercial |
$24.62
|
| 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
|
|
|
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 |
$0.04 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.13
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.19
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.12
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.11
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.13
|
| Rate for Payer: BCBS Transplant Transplant |
$0.13
|
| Rate for Payer: Blue Shield of California Commercial |
$0.14
|
| Rate for Payer: Blue Shield of California EPN |
$0.11
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Central Health Plan Commercial |
$0.18
|
| 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: 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 Management Network EPO/PPO |
$0.20
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.17
|
| Rate for Payer: IEHP medi-cal |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
| Rate for Payer: Networks By Design Commercial |
$0.14
|
| Rate for Payer: Prime Health Services Commercial |
$0.19
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.13
|
| Rate for Payer: Riverside University Health MISP |
$0.09
|
| 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 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 |
$0.04 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Blue Shield of California Commercial |
$0.17
|
| Rate for Payer: Blue Shield of California EPN |
$0.12
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Central Health Plan Commercial |
$0.18
|
| 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: Health Management Network EPO/PPO |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
| Rate for Payer: Networks By Design Commercial |
$0.14
|
| Rate for Payer: Prime Health Services Commercial |
$0.19
|
|
|
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 |
$0.08 |
| Max. Negotiated Rate |
$0.37 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.25
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.35
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.23
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.23
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.24
|
| Rate for Payer: BCBS Transplant Transplant |
$0.25
|
| Rate for Payer: Blue Shield of California Commercial |
$0.26
|
| Rate for Payer: Blue Shield of California EPN |
$0.20
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Central Health Plan Commercial |
$0.33
|
| 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: 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 Management Network EPO/PPO |
$0.37
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.31
|
| Rate for Payer: IEHP medi-cal |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.31
|
| Rate for Payer: Networks By Design Commercial |
$0.27
|
| Rate for Payer: Prime Health Services Commercial |
$0.35
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.25
|
| Rate for Payer: Riverside University Health MISP |
$0.16
|
| 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 Medi-Cal |
$0.35
|
| Rate for Payer: Vantage Medical Group Senior |
$0.35
|
|
|
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 |
$0.06 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Blue Shield of California Commercial |
$0.22
|
| Rate for Payer: Blue Shield of California EPN |
$0.15
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Central Health Plan Commercial |
$0.23
|
| 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: Health Management Network EPO/PPO |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.19
|
| 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 |
$0.19
|
| Rate for Payer: Prime Health Services Commercial |
$0.25
|
|
|
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 |
$0.08 |
| Max. Negotiated Rate |
$0.37 |
| Rate for Payer: Blue Shield of California Commercial |
$0.31
|
| Rate for Payer: Blue Shield of California EPN |
$0.22
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Central Health Plan Commercial |
$0.33
|
| 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: Health Management Network EPO/PPO |
$0.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.31
|
| Rate for Payer: Networks By Design Commercial |
$0.27
|
| Rate for Payer: Prime Health Services Commercial |
$0.35
|
|
|
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 |
$0.06 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.18
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.25
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.16
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.16
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.14
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.17
|
| Rate for Payer: BCBS Transplant Transplant |
$0.17
|
| Rate for Payer: Blue Shield of California Commercial |
$0.18
|
| Rate for Payer: Blue Shield of California EPN |
$0.14
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Central Health Plan Commercial |
$0.23
|
| 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: 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 Management Network EPO/PPO |
$0.26
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.22
|
| Rate for Payer: IEHP medi-cal |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.19
|
| 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 |
$0.19
|
| Rate for Payer: Prime Health Services Commercial |
$0.25
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.17
|
| Rate for Payer: Riverside University Health MISP |
$0.12
|
| 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 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 49884-055-01
|
| Hospital Charge Code |
1711197
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Blue Shield of California Commercial |
$0.22
|
| Rate for Payer: Blue Shield of California EPN |
$0.15
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Central Health Plan Commercial |
$0.23
|
| 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: Health Management Network EPO/PPO |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.19
|
| 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 |
$0.19
|
| 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 |
$0.06 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.18
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.25
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.16
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.16
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.14
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.17
|
| Rate for Payer: BCBS Transplant Transplant |
$0.17
|
| Rate for Payer: Blue Shield of California Commercial |
$0.18
|
| Rate for Payer: Blue Shield of California EPN |
$0.14
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Central Health Plan Commercial |
$0.23
|
| 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: 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 Management Network EPO/PPO |
$0.26
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.22
|
| Rate for Payer: IEHP medi-cal |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.19
|
| 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 |
$0.19
|
| Rate for Payer: Prime Health Services Commercial |
$0.25
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.17
|
| Rate for Payer: Riverside University Health MISP |
$0.12
|
| 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 Medi-Cal |
$0.25
|
| Rate for Payer: Vantage Medical Group Senior |
$0.25
|
|
|
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 |
$0.50 |
| Max. Negotiated Rate |
$2.25 |
| Rate for Payer: Blue Shield of California Commercial |
$1.88
|
| Rate for Payer: Blue Shield of California EPN |
$1.34
|
| Rate for Payer: Cash Price |
$1.13
|
| Rate for Payer: Central Health Plan Commercial |
$2.00
|
| 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: Health Management Network EPO/PPO |
$2.25
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.50
|
| Rate for Payer: Multiplan Commercial |
$1.88
|
| 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
IP
|
$7.50
|
|
|
Service Code
|
NDC 0168-0432-24
|
| Hospital Charge Code |
1743682
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$6.75 |
| Rate for Payer: Blue Shield of California Commercial |
$5.62
|
| Rate for Payer: Blue Shield of California EPN |
$4.00
|
| Rate for Payer: Cash Price |
$3.38
|
| Rate for Payer: Central Health Plan Commercial |
$6.00
|
| 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: Health Management Network EPO/PPO |
$6.75
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.50
|
| Rate for Payer: Multiplan Commercial |
$5.62
|
| 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
OP
|
$7.50
|
|
|
Service Code
|
NDC 0168-0432-24
|
| Hospital Charge Code |
1743682
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$6.75 |
| Rate for Payer: Aetna of CA HMO/PPO |
$4.55
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$6.38
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4.12
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4.12
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$3.63
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.43
|
| Rate for Payer: BCBS Transplant Transplant |
$4.50
|
| Rate for Payer: Blue Shield of California Commercial |
$4.72
|
| Rate for Payer: Blue Shield of California EPN |
$3.67
|
| Rate for Payer: Cash Price |
$3.38
|
| Rate for Payer: Central Health Plan Commercial |
$6.00
|
| 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: 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 Management Network EPO/PPO |
$6.75
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$5.62
|
| Rate for Payer: IEHP medi-cal |
$2.62
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.50
|
| Rate for Payer: Multiplan Commercial |
$5.62
|
| Rate for Payer: Networks By Design Commercial |
$4.88
|
| Rate for Payer: Prime Health Services Commercial |
$6.38
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$4.50
|
| Rate for Payer: Riverside University Health MISP |
$3.00
|
| 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 Medi-Cal |
$6.38
|
| Rate for Payer: Vantage Medical Group Senior |
$6.38
|
|
|
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 |
$0.50 |
| Max. Negotiated Rate |
$2.25 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.52
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.12
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.38
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.38
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1.21
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.48
|
| Rate for Payer: BCBS Transplant Transplant |
$1.50
|
| Rate for Payer: Blue Shield of California Commercial |
$1.57
|
| Rate for Payer: Blue Shield of California EPN |
$1.22
|
| Rate for Payer: Cash Price |
$1.13
|
| Rate for Payer: Central Health Plan Commercial |
$2.00
|
| 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: 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 Management Network EPO/PPO |
$2.25
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1.88
|
| Rate for Payer: IEHP medi-cal |
$0.88
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.50
|
| Rate for Payer: Multiplan Commercial |
$1.88
|
| Rate for Payer: Networks By Design Commercial |
$1.62
|
| Rate for Payer: Prime Health Services Commercial |
$2.12
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$1.50
|
| Rate for Payer: Riverside University Health MISP |
$1.00
|
| 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 Medi-Cal |
$2.12
|
| Rate for Payer: Vantage Medical Group Senior |
$2.12
|
|
|
IMIQUIMOD 5 % TOPICAL CREAM PACKET [20718]
|
Facility
IP
|
$2.50
|
|
|
Service Code
|
NDC 45802-368-62
|
| Hospital Charge Code |
1743682
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.50 |
| Max. Negotiated Rate |
$2.25 |
| Rate for Payer: Blue Shield of California Commercial |
$1.88
|
| Rate for Payer: Blue Shield of California EPN |
$1.34
|
| Rate for Payer: Cash Price |
$1.13
|
| Rate for Payer: Central Health Plan Commercial |
$2.00
|
| 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: Health Management Network EPO/PPO |
$2.25
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.50
|
| Rate for Payer: Multiplan Commercial |
$1.88
|
| Rate for Payer: Networks By Design Commercial |
$1.62
|
| Rate for Payer: Prime Health Services Commercial |
$2.12
|
|
