|
INCOBOTULINUMTOXINA 100 UNIT INTRAMUSCULAR SOLUTION [105971]
|
Facility
|
IP
|
$613.20
|
|
|
Service Code
|
HCPCS J0588
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$122.64 |
| Max. Negotiated Rate |
$551.88 |
| Rate for Payer: Adventist Health Commercial |
$122.64
|
| Rate for Payer: Blue Shield of California Commercial |
$474.00
|
| Rate for Payer: Blue Shield of California EPN |
$309.05
|
| Rate for Payer: Cash Price |
$337.26
|
| Rate for Payer: Central Health Plan Commercial |
$490.56
|
| Rate for Payer: Cigna of CA HMO |
$429.24
|
| Rate for Payer: Cigna of CA PPO |
$429.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$245.28
|
| Rate for Payer: EPIC Health Plan Senior |
$245.28
|
| Rate for Payer: Galaxy Health WC |
$521.22
|
| Rate for Payer: Global Benefits Group Commercial |
$367.92
|
| Rate for Payer: Health Management Network EPO/PPO |
$551.88
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$409.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$233.63
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$379.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$122.64
|
| Rate for Payer: Multiplan Commercial |
$459.90
|
| Rate for Payer: Networks By Design Commercial |
$306.60
|
| Rate for Payer: Prime Health Services Commercial |
$521.22
|
| Rate for Payer: United Healthcare All Other Commercial |
$230.13
|
| Rate for Payer: United Healthcare All Other HMO |
$224.00
|
| Rate for Payer: United Healthcare HMO Rider |
$219.16
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$200.82
|
|
|
INCOBOTULINUMTOXINA 100 UNIT INTRAMUSCULAR SOLUTION [105971]
|
Facility
|
OP
|
$613.20
|
|
|
Service Code
|
HCPCS J0588
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.50 |
| Max. Negotiated Rate |
$551.88 |
| Rate for Payer: Adventist Health Commercial |
$122.64
|
| Rate for Payer: Adventist Health Medi-Cal |
$5.31
|
| Rate for Payer: Aetna of CA HMO/PPO |
$372.40
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.63
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5.84
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.84
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$11.42
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.50
|
| Rate for Payer: Blue Shield of California Commercial |
$6.85
|
| Rate for Payer: Blue Shield of California EPN |
$6.23
|
| Rate for Payer: Cash Price |
$337.26
|
| Rate for Payer: Cash Price |
$337.26
|
| Rate for Payer: Central Health Plan Commercial |
$490.56
|
| Rate for Payer: Cigna of CA HMO |
$429.24
|
| Rate for Payer: Cigna of CA PPO |
$429.24
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.63
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.84
|
| Rate for Payer: Dignity Health Medicare Advantage |
$5.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.16
|
| Rate for Payer: EPIC Health Plan Senior |
$5.31
|
| Rate for Payer: Galaxy Health WC |
$521.22
|
| Rate for Payer: Global Benefits Group Commercial |
$367.92
|
| Rate for Payer: Health Management Network EPO/PPO |
$551.88
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$8.70
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$5.33
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$5.31
|
| Rate for Payer: InnovAge PACE Commercial |
$7.96
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$409.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$18.56
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$122.64
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$7.11
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$7.11
|
| Rate for Payer: Multiplan Commercial |
$459.90
|
| Rate for Payer: Networks By Design Commercial |
$306.60
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$5.31
|
| Rate for Payer: Prime Health Services Commercial |
$521.22
|
| Rate for Payer: Prime Health Services Medicare |
$5.63
|
| Rate for Payer: Riverside University Health System MISP |
$5.84
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$367.92
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$367.92
|
| Rate for Payer: United Healthcare All Other Commercial |
$230.13
|
| Rate for Payer: United Healthcare All Other HMO |
$224.00
|
| Rate for Payer: United Healthcare HMO Rider |
$219.16
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$200.82
|
| Rate for Payer: Upland Medical Group Pediatric |
$5.31
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6.63
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.84
|
| Rate for Payer: Vantage Medical Group Senior |
$5.84
|
|
|
INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INTRAVENOUS SOLUTION [235583]
|
Facility
|
IP
|
$96.00
|
|
|
Service Code
|
HCPCS J9220
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$19.20 |
| Max. Negotiated Rate |
$86.40 |
| Rate for Payer: Adventist Health Commercial |
$19.20
|
| Rate for Payer: Blue Shield of California Commercial |
$74.21
|
| Rate for Payer: Blue Shield of California EPN |
$48.38
|
| Rate for Payer: Cash Price |
$52.80
|
| Rate for Payer: Central Health Plan Commercial |
$76.80
|
| Rate for Payer: Cigna of CA HMO |
$67.20
|
| Rate for Payer: Cigna of CA PPO |
$67.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$38.40
|
| Rate for Payer: EPIC Health Plan Senior |
$38.40
|
| Rate for Payer: Galaxy Health WC |
$81.60
|
| Rate for Payer: Global Benefits Group Commercial |
$57.60
|
| Rate for Payer: Health Management Network EPO/PPO |
$86.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$64.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$36.58
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$59.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$19.20
|
| Rate for Payer: Multiplan Commercial |
$72.00
|
| Rate for Payer: Networks By Design Commercial |
$48.00
|
| Rate for Payer: Prime Health Services Commercial |
$81.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$36.03
|
| Rate for Payer: United Healthcare All Other HMO |
$35.07
|
| Rate for Payer: United Healthcare HMO Rider |
$34.31
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$31.44
|
|
|
INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INTRAVENOUS SOLUTION [235583]
|
Facility
|
OP
|
$96.00
|
|
|
Service Code
|
HCPCS J9220
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.75 |
| Max. Negotiated Rate |
$86.40 |
| Rate for Payer: Adventist Health Commercial |
$19.20
|
| Rate for Payer: Adventist Health Medi-Cal |
$9.96
|
| Rate for Payer: Aetna of CA HMO/PPO |
$58.30
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$14.93
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$10.95
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9.96
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$21.99
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6.75
|
| Rate for Payer: Blue Shield of California Commercial |
$58.66
|
| Rate for Payer: Blue Shield of California EPN |
$38.30
|
| Rate for Payer: Cash Price |
$52.80
|
| Rate for Payer: Cash Price |
$52.80
|
| Rate for Payer: Central Health Plan Commercial |
$76.80
|
| Rate for Payer: Cigna of CA HMO |
$67.20
|
| Rate for Payer: Cigna of CA PPO |
$67.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$14.93
|
| Rate for Payer: Dignity Health Medi-Cal |
$10.95
|
| Rate for Payer: Dignity Health Medicare Advantage |
$9.96
|
| Rate for Payer: EPIC Health Plan Commercial |
$13.44
|
| Rate for Payer: EPIC Health Plan Senior |
$9.96
|
| Rate for Payer: Galaxy Health WC |
$81.60
|
| Rate for Payer: Global Benefits Group Commercial |
$57.60
|
| Rate for Payer: Health Management Network EPO/PPO |
$86.40
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$16.33
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$9.96
|
| Rate for Payer: InnovAge PACE Commercial |
$14.93
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$64.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$36.58
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$9.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$19.20
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$13.34
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$13.34
|
| Rate for Payer: Multiplan Commercial |
$72.00
|
| Rate for Payer: Networks By Design Commercial |
$48.00
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$9.96
|
| Rate for Payer: Prime Health Services Commercial |
$81.60
|
| Rate for Payer: Prime Health Services Medicare |
$10.55
|
| Rate for Payer: Riverside University Health System MISP |
$10.95
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$57.60
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$57.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$36.03
|
| Rate for Payer: United Healthcare All Other HMO |
$35.07
|
| Rate for Payer: United Healthcare HMO Rider |
$34.31
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$31.44
|
| Rate for Payer: Upland Medical Group Pediatric |
$9.96
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$14.93
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$10.95
|
| Rate for Payer: Vantage Medical Group Senior |
$9.96
|
|
|
INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION [10266]
|
Facility
|
IP
|
$343.00
|
|
|
Service Code
|
NDC 70100-725-01
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$68.60 |
| Max. Negotiated Rate |
$308.70 |
| Rate for Payer: Adventist Health Commercial |
$68.60
|
| Rate for Payer: Blue Shield of California Commercial |
$265.14
|
| Rate for Payer: Blue Shield of California EPN |
$172.87
|
| Rate for Payer: Cash Price |
$188.65
|
| Rate for Payer: Central Health Plan Commercial |
$274.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$137.20
|
| Rate for Payer: EPIC Health Plan Senior |
$137.20
|
| Rate for Payer: Galaxy Health WC |
$291.55
|
| Rate for Payer: Global Benefits Group Commercial |
$205.80
|
| Rate for Payer: Health Management Network EPO/PPO |
$308.70
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$228.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$130.68
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$212.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$68.60
|
| Rate for Payer: Multiplan Commercial |
$257.25
|
| Rate for Payer: Networks By Design Commercial |
$222.95
|
| Rate for Payer: Prime Health Services Commercial |
$291.55
|
|
|
INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION [10266]
|
Facility
|
OP
|
$343.00
|
|
|
Service Code
|
NDC 70100-825-02
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$68.60 |
| Max. Negotiated Rate |
$308.70 |
| Rate for Payer: Adventist Health Commercial |
$68.60
|
| Rate for Payer: Aetna of CA HMO/PPO |
$208.30
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$291.55
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$188.65
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$257.25
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$166.08
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$201.44
|
| Rate for Payer: Blue Shield of California Commercial |
$209.57
|
| Rate for Payer: Blue Shield of California EPN |
$136.86
|
| Rate for Payer: Cash Price |
$188.65
|
| Rate for Payer: Central Health Plan Commercial |
$274.40
|
| Rate for Payer: Cigna of CA HMO |
$219.52
|
| Rate for Payer: Cigna of CA PPO |
$253.82
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$291.55
|
| Rate for Payer: Dignity Health Medi-Cal |
$291.55
|
| Rate for Payer: Dignity Health Medicare Advantage |
$291.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$137.20
|
| Rate for Payer: EPIC Health Plan Senior |
$137.20
|
| Rate for Payer: Galaxy Health WC |
$291.55
|
| Rate for Payer: Global Benefits Group Commercial |
$205.80
|
| Rate for Payer: Health Management Network EPO/PPO |
$308.70
|
| Rate for Payer: InnovAge PACE Commercial |
$171.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$228.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$130.68
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$212.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$68.60
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$240.10
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$240.10
|
| Rate for Payer: Multiplan Commercial |
$257.25
|
| Rate for Payer: Networks By Design Commercial |
$222.95
|
| Rate for Payer: Prime Health Services Commercial |
$291.55
|
| Rate for Payer: Riverside University Health System MISP |
$137.20
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$205.80
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$205.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$171.50
|
| Rate for Payer: United Healthcare All Other HMO |
$171.50
|
| Rate for Payer: United Healthcare HMO Rider |
$171.50
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$171.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$291.55
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$291.55
|
| Rate for Payer: Vantage Medical Group Senior |
$291.55
|
|
|
INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION [10266]
|
Facility
|
IP
|
$343.00
|
|
|
Service Code
|
NDC 70100-825-02
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$68.60 |
| Max. Negotiated Rate |
$308.70 |
| Rate for Payer: Adventist Health Commercial |
$68.60
|
| Rate for Payer: Blue Shield of California Commercial |
$265.14
|
| Rate for Payer: Blue Shield of California EPN |
$172.87
|
| Rate for Payer: Cash Price |
$188.65
|
| Rate for Payer: Central Health Plan Commercial |
$274.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$137.20
|
| Rate for Payer: EPIC Health Plan Senior |
$137.20
|
| Rate for Payer: Galaxy Health WC |
$291.55
|
| Rate for Payer: Global Benefits Group Commercial |
$205.80
|
| Rate for Payer: Health Management Network EPO/PPO |
$308.70
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$228.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$130.68
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$212.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$68.60
|
| Rate for Payer: Multiplan Commercial |
$257.25
|
| Rate for Payer: Networks By Design Commercial |
$222.95
|
| Rate for Payer: Prime Health Services Commercial |
$291.55
|
|
|
INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION [10266]
|
Facility
|
OP
|
$343.00
|
|
|
Service Code
|
NDC 70100-725-01
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$68.60 |
| Max. Negotiated Rate |
$308.70 |
| Rate for Payer: Adventist Health Commercial |
$68.60
|
| Rate for Payer: Aetna of CA HMO/PPO |
$208.30
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$291.55
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$188.65
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$257.25
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$166.08
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$201.44
|
| Rate for Payer: Blue Shield of California Commercial |
$209.57
|
| Rate for Payer: Blue Shield of California EPN |
$136.86
|
| Rate for Payer: Cash Price |
$188.65
|
| Rate for Payer: Central Health Plan Commercial |
$274.40
|
| Rate for Payer: Cigna of CA HMO |
$219.52
|
| Rate for Payer: Cigna of CA PPO |
$253.82
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$291.55
|
| Rate for Payer: Dignity Health Medi-Cal |
$291.55
|
| Rate for Payer: Dignity Health Medicare Advantage |
$291.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$137.20
|
| Rate for Payer: EPIC Health Plan Senior |
$137.20
|
| Rate for Payer: Galaxy Health WC |
$291.55
|
| Rate for Payer: Global Benefits Group Commercial |
$205.80
|
| Rate for Payer: Health Management Network EPO/PPO |
$308.70
|
| Rate for Payer: InnovAge PACE Commercial |
$171.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$228.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$130.68
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$212.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$68.60
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$240.10
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$240.10
|
| Rate for Payer: Multiplan Commercial |
$257.25
|
| Rate for Payer: Networks By Design Commercial |
$222.95
|
| Rate for Payer: Prime Health Services Commercial |
$291.55
|
| Rate for Payer: Riverside University Health System MISP |
$137.20
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$205.80
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$205.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$171.50
|
| Rate for Payer: United Healthcare All Other HMO |
$171.50
|
| Rate for Payer: United Healthcare HMO Rider |
$171.50
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$171.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$291.55
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$291.55
|
| Rate for Payer: Vantage Medical Group Senior |
$291.55
|
|
|
INDOMETHACIN 1 MG INTRAVENOUS SOLUTION [10267]
|
Facility
|
OP
|
$445.49
|
|
|
Service Code
|
NDC 63323-659-94
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$89.10 |
| Max. Negotiated Rate |
$400.94 |
| Rate for Payer: Adventist Health Commercial |
$89.10
|
| Rate for Payer: Aetna of CA HMO/PPO |
$270.55
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$378.67
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$245.02
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$334.12
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$215.71
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$261.64
|
| Rate for Payer: Blue Shield of California Commercial |
$272.19
|
| Rate for Payer: Blue Shield of California EPN |
$177.75
|
| Rate for Payer: Cash Price |
$245.02
|
| Rate for Payer: Central Health Plan Commercial |
$356.39
|
| Rate for Payer: Cigna of CA HMO |
$285.11
|
| Rate for Payer: Cigna of CA PPO |
$329.66
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$378.67
|
| Rate for Payer: Dignity Health Medi-Cal |
$378.67
|
| Rate for Payer: Dignity Health Medicare Advantage |
$378.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$178.20
|
| Rate for Payer: EPIC Health Plan Senior |
$178.20
|
| Rate for Payer: Galaxy Health WC |
$378.67
|
| Rate for Payer: Global Benefits Group Commercial |
$267.29
|
| Rate for Payer: Health Management Network EPO/PPO |
$400.94
|
| Rate for Payer: InnovAge PACE Commercial |
$222.75
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$297.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$169.73
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$275.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$89.10
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$311.84
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$311.84
|
| Rate for Payer: Multiplan Commercial |
$334.12
|
| Rate for Payer: Networks By Design Commercial |
$289.57
|
| Rate for Payer: Prime Health Services Commercial |
$378.67
|
| Rate for Payer: Riverside University Health System MISP |
$178.20
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$267.29
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$267.29
|
| Rate for Payer: United Healthcare All Other Commercial |
$222.75
|
| Rate for Payer: United Healthcare All Other HMO |
$222.75
|
| Rate for Payer: United Healthcare HMO Rider |
$222.75
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$222.75
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$378.67
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$378.67
|
| Rate for Payer: Vantage Medical Group Senior |
$378.67
|
|
|
INDOMETHACIN 1 MG INTRAVENOUS SOLUTION [10267]
|
Facility
|
IP
|
$445.49
|
|
|
Service Code
|
NDC 63323-659-94
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$89.10 |
| Max. Negotiated Rate |
$400.94 |
| Rate for Payer: Adventist Health Commercial |
$89.10
|
| Rate for Payer: Blue Shield of California Commercial |
$344.36
|
| Rate for Payer: Blue Shield of California EPN |
$224.53
|
| Rate for Payer: Cash Price |
$245.02
|
| Rate for Payer: Central Health Plan Commercial |
$356.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$178.20
|
| Rate for Payer: EPIC Health Plan Senior |
$178.20
|
| Rate for Payer: Galaxy Health WC |
$378.67
|
| Rate for Payer: Global Benefits Group Commercial |
$267.29
|
| Rate for Payer: Health Management Network EPO/PPO |
$400.94
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$297.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$169.73
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$275.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$89.10
|
| Rate for Payer: Multiplan Commercial |
$334.12
|
| Rate for Payer: Networks By Design Commercial |
$289.57
|
| Rate for Payer: Prime Health Services Commercial |
$378.67
|
|
|
INDOMETHACIN 25 MG CAPSULE [3897]
|
Facility
|
OP
|
$0.26
|
|
|
Service Code
|
NDC 68462-406-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.16
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.22
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.20
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.13
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.15
|
| Rate for Payer: Blue Shield of California Commercial |
$0.16
|
| Rate for Payer: Blue Shield of California EPN |
$0.10
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Central Health Plan Commercial |
$0.21
|
| Rate for Payer: Cigna of CA HMO |
$0.18
|
| Rate for Payer: Cigna of CA PPO |
$0.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.22
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: EPIC Health Plan Senior |
$0.10
|
| Rate for Payer: Galaxy Health WC |
$0.22
|
| Rate for Payer: Global Benefits Group Commercial |
$0.16
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.23
|
| Rate for Payer: InnovAge PACE Commercial |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.18
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
| Rate for Payer: Networks By Design Commercial |
$0.17
|
| Rate for Payer: Prime Health Services Commercial |
$0.22
|
| Rate for Payer: Riverside University Health System MISP |
$0.10
|
| 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 |
$0.13
|
| Rate for Payer: United Healthcare All Other HMO |
$0.13
|
| Rate for Payer: United Healthcare HMO Rider |
$0.13
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.13
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.22
|
| Rate for Payer: Vantage Medical Group Senior |
$0.22
|
|
|
INDOMETHACIN 25 MG CAPSULE [3897]
|
Facility
|
IP
|
$0.43
|
|
|
Service Code
|
NDC 50268-430-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.39 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Blue Shield of California Commercial |
$0.33
|
| Rate for Payer: Blue Shield of California EPN |
$0.22
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: Central Health Plan Commercial |
$0.34
|
| Rate for Payer: Cigna of CA HMO |
$0.30
|
| Rate for Payer: Cigna of CA PPO |
$0.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: EPIC Health Plan Senior |
$0.17
|
| Rate for Payer: Galaxy Health WC |
$0.37
|
| Rate for Payer: Global Benefits Group Commercial |
$0.26
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.39
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.32
|
| Rate for Payer: Networks By Design Commercial |
$0.28
|
| Rate for Payer: Prime Health Services Commercial |
$0.37
|
|
|
INDOMETHACIN 25 MG CAPSULE [3897]
|
Facility
|
IP
|
$0.26
|
|
|
Service Code
|
NDC 68462-406-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Blue Shield of California Commercial |
$0.20
|
| Rate for Payer: Blue Shield of California EPN |
$0.13
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Central Health Plan Commercial |
$0.21
|
| Rate for Payer: Cigna of CA HMO |
$0.18
|
| Rate for Payer: Cigna of CA PPO |
$0.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: EPIC Health Plan Senior |
$0.10
|
| Rate for Payer: Galaxy Health WC |
$0.22
|
| Rate for Payer: Global Benefits Group Commercial |
$0.16
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
| Rate for Payer: Networks By Design Commercial |
$0.17
|
| Rate for Payer: Prime Health Services Commercial |
$0.22
|
|
|
INDOMETHACIN 25 MG CAPSULE [3897]
|
Facility
|
IP
|
$0.43
|
|
|
Service Code
|
NDC 50268-430-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.39 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Blue Shield of California Commercial |
$0.33
|
| Rate for Payer: Blue Shield of California EPN |
$0.22
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: Central Health Plan Commercial |
$0.34
|
| Rate for Payer: Cigna of CA HMO |
$0.30
|
| Rate for Payer: Cigna of CA PPO |
$0.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: EPIC Health Plan Senior |
$0.17
|
| Rate for Payer: Galaxy Health WC |
$0.37
|
| Rate for Payer: Global Benefits Group Commercial |
$0.26
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.39
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.32
|
| Rate for Payer: Networks By Design Commercial |
$0.28
|
| Rate for Payer: Prime Health Services Commercial |
$0.37
|
|
|
INDOMETHACIN 25 MG CAPSULE [3897]
|
Facility
|
OP
|
$0.43
|
|
|
Service Code
|
NDC 50268-430-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.39 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.26
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.37
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.24
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.32
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.21
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.25
|
| Rate for Payer: Blue Shield of California Commercial |
$0.26
|
| Rate for Payer: Blue Shield of California EPN |
$0.17
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: Central Health Plan Commercial |
$0.34
|
| Rate for Payer: Cigna of CA HMO |
$0.30
|
| Rate for Payer: Cigna of CA PPO |
$0.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.37
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: EPIC Health Plan Senior |
$0.17
|
| Rate for Payer: Galaxy Health WC |
$0.37
|
| Rate for Payer: Global Benefits Group Commercial |
$0.26
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.39
|
| Rate for Payer: InnovAge PACE Commercial |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.30
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.30
|
| Rate for Payer: Multiplan Commercial |
$0.32
|
| Rate for Payer: Networks By Design Commercial |
$0.28
|
| Rate for Payer: Prime Health Services Commercial |
$0.37
|
| Rate for Payer: Riverside University Health System MISP |
$0.17
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.26
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.26
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.22
|
| Rate for Payer: United Healthcare All Other HMO |
$0.22
|
| Rate for Payer: United Healthcare HMO Rider |
$0.22
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.22
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.37
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.37
|
| Rate for Payer: Vantage Medical Group Senior |
$0.37
|
|
|
INDOMETHACIN 25 MG CAPSULE [3897]
|
Facility
|
OP
|
$0.43
|
|
|
Service Code
|
NDC 50268-430-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.39 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.26
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.37
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.24
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.32
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.21
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.25
|
| Rate for Payer: Blue Shield of California Commercial |
$0.26
|
| Rate for Payer: Blue Shield of California EPN |
$0.17
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: Central Health Plan Commercial |
$0.34
|
| Rate for Payer: Cigna of CA HMO |
$0.30
|
| Rate for Payer: Cigna of CA PPO |
$0.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.37
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: EPIC Health Plan Senior |
$0.17
|
| Rate for Payer: Galaxy Health WC |
$0.37
|
| Rate for Payer: Global Benefits Group Commercial |
$0.26
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.39
|
| Rate for Payer: InnovAge PACE Commercial |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.30
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.30
|
| Rate for Payer: Multiplan Commercial |
$0.32
|
| Rate for Payer: Networks By Design Commercial |
$0.28
|
| Rate for Payer: Prime Health Services Commercial |
$0.37
|
| Rate for Payer: Riverside University Health System MISP |
$0.17
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.26
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.26
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.22
|
| Rate for Payer: United Healthcare All Other HMO |
$0.22
|
| Rate for Payer: United Healthcare HMO Rider |
$0.22
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.22
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.37
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.37
|
| Rate for Payer: Vantage Medical Group Senior |
$0.37
|
|
|
INDOMETHACIN 50 MG CAPSULE [3898]
|
Facility
|
IP
|
$0.39
|
|
|
Service Code
|
NDC 50268-431-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.35 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Blue Shield of California Commercial |
$0.30
|
| Rate for Payer: Blue Shield of California EPN |
$0.20
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Central Health Plan Commercial |
$0.31
|
| Rate for Payer: Cigna of CA HMO |
$0.27
|
| Rate for Payer: Cigna of CA PPO |
$0.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| Rate for Payer: EPIC Health Plan Senior |
$0.16
|
| Rate for Payer: Galaxy Health WC |
$0.33
|
| Rate for Payer: Global Benefits Group Commercial |
$0.23
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.35
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.29
|
| Rate for Payer: Networks By Design Commercial |
$0.25
|
| Rate for Payer: Prime Health Services Commercial |
$0.33
|
|
|
INDOMETHACIN 50 MG CAPSULE [3898]
|
Facility
|
OP
|
$0.33
|
|
|
Service Code
|
NDC 68462-302-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.30 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.20
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.28
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.18
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.25
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.16
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.19
|
| Rate for Payer: Blue Shield of California Commercial |
$0.20
|
| Rate for Payer: Blue Shield of California EPN |
$0.13
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Central Health Plan Commercial |
$0.26
|
| Rate for Payer: Cigna of CA HMO |
$0.23
|
| Rate for Payer: Cigna of CA PPO |
$0.23
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.28
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.28
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.13
|
| Rate for Payer: EPIC Health Plan Senior |
$0.13
|
| Rate for Payer: Galaxy Health WC |
$0.28
|
| Rate for Payer: Global Benefits Group Commercial |
$0.20
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.30
|
| Rate for Payer: InnovAge PACE Commercial |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.23
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.23
|
| Rate for Payer: Multiplan Commercial |
$0.25
|
| Rate for Payer: Networks By Design Commercial |
$0.21
|
| Rate for Payer: Prime Health Services Commercial |
$0.28
|
| Rate for Payer: Riverside University Health System MISP |
$0.13
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.20
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.20
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.17
|
| Rate for Payer: United Healthcare All Other HMO |
$0.17
|
| Rate for Payer: United Healthcare HMO Rider |
$0.17
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.17
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.28
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.28
|
| Rate for Payer: Vantage Medical Group Senior |
$0.28
|
|
|
INDOMETHACIN 50 MG CAPSULE [3898]
|
Facility
|
OP
|
$0.39
|
|
|
Service Code
|
NDC 50268-431-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.35 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.24
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.33
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.21
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.29
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.19
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.23
|
| Rate for Payer: Blue Shield of California Commercial |
$0.24
|
| Rate for Payer: Blue Shield of California EPN |
$0.16
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Central Health Plan Commercial |
$0.31
|
| Rate for Payer: Cigna of CA HMO |
$0.27
|
| Rate for Payer: Cigna of CA PPO |
$0.27
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.33
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.33
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| Rate for Payer: EPIC Health Plan Senior |
$0.16
|
| Rate for Payer: Galaxy Health WC |
$0.33
|
| Rate for Payer: Global Benefits Group Commercial |
$0.23
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.35
|
| Rate for Payer: InnovAge PACE Commercial |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.27
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.27
|
| Rate for Payer: Multiplan Commercial |
$0.29
|
| Rate for Payer: Networks By Design Commercial |
$0.25
|
| Rate for Payer: Prime Health Services Commercial |
$0.33
|
| Rate for Payer: Riverside University Health System MISP |
$0.16
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.23
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.23
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.20
|
| Rate for Payer: United Healthcare All Other HMO |
$0.20
|
| Rate for Payer: United Healthcare HMO Rider |
$0.20
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.20
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.33
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.33
|
| Rate for Payer: Vantage Medical Group Senior |
$0.33
|
|
|
INDOMETHACIN 50 MG CAPSULE [3898]
|
Facility
|
IP
|
$0.33
|
|
|
Service Code
|
NDC 68462-302-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.30 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Blue Shield of California Commercial |
$0.26
|
| Rate for Payer: Blue Shield of California EPN |
$0.17
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Central Health Plan Commercial |
$0.26
|
| Rate for Payer: Cigna of CA HMO |
$0.23
|
| Rate for Payer: Cigna of CA PPO |
$0.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.13
|
| Rate for Payer: EPIC Health Plan Senior |
$0.13
|
| Rate for Payer: Galaxy Health WC |
$0.28
|
| Rate for Payer: Global Benefits Group Commercial |
$0.20
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.25
|
| Rate for Payer: Networks By Design Commercial |
$0.21
|
| Rate for Payer: Prime Health Services Commercial |
$0.28
|
|
|
INDOMETHACIN 50 MG RECTAL SUPPOSITORY [3901]
|
Facility
|
IP
|
$434.29
|
|
|
Service Code
|
NDC 69344-102-33
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$86.86 |
| Max. Negotiated Rate |
$390.86 |
| Rate for Payer: Adventist Health Commercial |
$86.86
|
| Rate for Payer: Blue Shield of California Commercial |
$335.71
|
| Rate for Payer: Blue Shield of California EPN |
$218.88
|
| Rate for Payer: Cash Price |
$238.86
|
| Rate for Payer: Central Health Plan Commercial |
$347.43
|
| Rate for Payer: Cigna of CA HMO |
$304.00
|
| Rate for Payer: Cigna of CA PPO |
$304.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$173.72
|
| Rate for Payer: EPIC Health Plan Senior |
$173.72
|
| Rate for Payer: Galaxy Health WC |
$369.15
|
| Rate for Payer: Global Benefits Group Commercial |
$260.57
|
| Rate for Payer: Health Management Network EPO/PPO |
$390.86
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$289.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$165.46
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$268.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$86.86
|
| Rate for Payer: Multiplan Commercial |
$325.72
|
| Rate for Payer: Networks By Design Commercial |
$282.29
|
| Rate for Payer: Prime Health Services Commercial |
$369.15
|
|
|
INDOMETHACIN 50 MG RECTAL SUPPOSITORY [3901]
|
Facility
|
OP
|
$434.29
|
|
|
Service Code
|
NDC 69344-102-33
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$86.86 |
| Max. Negotiated Rate |
$390.86 |
| Rate for Payer: Adventist Health Commercial |
$86.86
|
| Rate for Payer: Aetna of CA HMO/PPO |
$263.74
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$369.15
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$238.86
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$325.72
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$210.28
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$255.06
|
| Rate for Payer: Blue Shield of California Commercial |
$265.35
|
| Rate for Payer: Blue Shield of California EPN |
$173.28
|
| Rate for Payer: Cash Price |
$238.86
|
| Rate for Payer: Central Health Plan Commercial |
$347.43
|
| Rate for Payer: Cigna of CA HMO |
$304.00
|
| Rate for Payer: Cigna of CA PPO |
$304.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$369.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$369.15
|
| Rate for Payer: Dignity Health Medicare Advantage |
$369.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$173.72
|
| Rate for Payer: EPIC Health Plan Senior |
$173.72
|
| Rate for Payer: Galaxy Health WC |
$369.15
|
| Rate for Payer: Global Benefits Group Commercial |
$260.57
|
| Rate for Payer: Health Management Network EPO/PPO |
$390.86
|
| Rate for Payer: InnovAge PACE Commercial |
$217.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$289.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$165.46
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$268.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$86.86
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$304.00
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$304.00
|
| Rate for Payer: Multiplan Commercial |
$325.72
|
| Rate for Payer: Networks By Design Commercial |
$282.29
|
| Rate for Payer: Prime Health Services Commercial |
$369.15
|
| Rate for Payer: Riverside University Health System MISP |
$173.72
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$260.57
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$260.57
|
| Rate for Payer: United Healthcare All Other Commercial |
$217.15
|
| Rate for Payer: United Healthcare All Other HMO |
$217.15
|
| Rate for Payer: United Healthcare HMO Rider |
$217.15
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$217.15
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$369.15
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$369.15
|
| Rate for Payer: Vantage Medical Group Senior |
$369.15
|
|
|
INDOMETHACIN ER 75 MG CAPSULE,EXTENDED RELEASE [14628]
|
Facility
|
IP
|
$0.42
|
|
|
Service Code
|
NDC 68462-325-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.38 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Blue Shield of California Commercial |
$0.32
|
| Rate for Payer: Blue Shield of California EPN |
$0.21
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Central Health Plan Commercial |
$0.34
|
| Rate for Payer: Cigna of CA HMO |
$0.29
|
| Rate for Payer: Cigna of CA PPO |
$0.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: EPIC Health Plan Senior |
$0.17
|
| Rate for Payer: Galaxy Health WC |
$0.36
|
| Rate for Payer: Global Benefits Group Commercial |
$0.25
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.38
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.32
|
| Rate for Payer: Networks By Design Commercial |
$0.27
|
| Rate for Payer: Prime Health Services Commercial |
$0.36
|
|
|
INDOMETHACIN ER 75 MG CAPSULE,EXTENDED RELEASE [14628]
|
Facility
|
OP
|
$0.42
|
|
|
Service Code
|
NDC 68462-325-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.38 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.26
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.36
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.23
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.32
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.25
|
| Rate for Payer: Blue Shield of California Commercial |
$0.26
|
| Rate for Payer: Blue Shield of California EPN |
$0.17
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Central Health Plan Commercial |
$0.34
|
| Rate for Payer: Cigna of CA HMO |
$0.29
|
| Rate for Payer: Cigna of CA PPO |
$0.29
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.36
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.36
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: EPIC Health Plan Senior |
$0.17
|
| Rate for Payer: Galaxy Health WC |
$0.36
|
| Rate for Payer: Global Benefits Group Commercial |
$0.25
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.38
|
| Rate for Payer: InnovAge PACE Commercial |
$0.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.29
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.29
|
| Rate for Payer: Multiplan Commercial |
$0.32
|
| Rate for Payer: Networks By Design Commercial |
$0.27
|
| Rate for Payer: Prime Health Services Commercial |
$0.36
|
| Rate for Payer: Riverside University Health System MISP |
$0.17
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.25
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.25
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.21
|
| Rate for Payer: United Healthcare All Other HMO |
$0.21
|
| Rate for Payer: United Healthcare HMO Rider |
$0.21
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.21
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.36
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.36
|
| Rate for Payer: Vantage Medical Group Senior |
$0.36
|
|
|
INFLIXIMAB 100 MG INTRAVENOUS SOLUTION [23796]
|
Facility
|
IP
|
$570.00
|
|
|
Service Code
|
HCPCS J1745
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$114.00 |
| Max. Negotiated Rate |
$513.00 |
| Rate for Payer: Adventist Health Commercial |
$114.00
|
| Rate for Payer: Blue Shield of California Commercial |
$440.61
|
| Rate for Payer: Blue Shield of California EPN |
$287.28
|
| Rate for Payer: Cash Price |
$313.50
|
| Rate for Payer: Central Health Plan Commercial |
$456.00
|
| Rate for Payer: Cigna of CA HMO |
$399.00
|
| Rate for Payer: Cigna of CA PPO |
$399.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$228.00
|
| Rate for Payer: EPIC Health Plan Senior |
$228.00
|
| Rate for Payer: Galaxy Health WC |
$484.50
|
| Rate for Payer: Global Benefits Group Commercial |
$342.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$513.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$380.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$217.17
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$352.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$114.00
|
| Rate for Payer: Multiplan Commercial |
$427.50
|
| Rate for Payer: Networks By Design Commercial |
$285.00
|
| Rate for Payer: Prime Health Services Commercial |
$484.50
|
| Rate for Payer: United Healthcare All Other Commercial |
$213.92
|
| Rate for Payer: United Healthcare All Other HMO |
$208.22
|
| Rate for Payer: United Healthcare HMO Rider |
$203.72
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$186.68
|
|
