|
LUTETIUM LU-177 VIPIVOTIDE TETRAXETAN 27 MCI/ML (1,000 MBQ/ML) IV SOLN [233901]
|
Facility
OP
|
$52,020.00
|
|
|
Service Code
|
CPT A9607
|
| Hospital Charge Code |
NDG233901
|
|
Hospital Revenue Code
|
344
|
| Min. Negotiated Rate |
$229.76 |
| Max. Negotiated Rate |
$46,818.00 |
| Rate for Payer: Adventist Health Medi-Cal |
$229.76
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1,390.84
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$344.63
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$252.73
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$229.76
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$420.56
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$460.47
|
| Rate for Payer: BCBS Transplant Transplant |
$31,212.00
|
| Rate for Payer: Blue Shield of California Commercial |
$32,148.36
|
| Rate for Payer: Blue Shield of California EPN |
$25,281.72
|
| Rate for Payer: Caremore Medicare Advantage |
$229.76
|
| Rate for Payer: Cash Price |
$23,409.00
|
| Rate for Payer: Cash Price |
$23,409.00
|
| Rate for Payer: Central Health Plan Commercial |
$41,616.00
|
| Rate for Payer: Cigna of CA HMO |
$33,292.80
|
| Rate for Payer: Cigna of CA PPO |
$38,494.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$287.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$310.17
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$229.76
|
| Rate for Payer: EPIC Health Plan Transplant |
$229.76
|
| Rate for Payer: Galaxy Health WC |
$44,217.00
|
| Rate for Payer: Global Benefits Group Commercial |
$31,212.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$46,818.00
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$39,015.00
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$376.80
|
| Rate for Payer: IEHP medi-cal |
$379.10
|
| Rate for Payer: IEHP Medicare Advantage |
$229.76
|
| Rate for Payer: Innovage PACE Commercial |
$344.63
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$34,697.34
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$229.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10,404.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$307.87
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$307.87
|
| Rate for Payer: Multiplan Commercial |
$39,015.00
|
| Rate for Payer: Networks By Design Commercial |
$33,813.00
|
| Rate for Payer: Prime Health Services Commercial |
$44,217.00
|
| Rate for Payer: Prime Health Services Medicare |
$243.54
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$31,212.00
|
| Rate for Payer: Riverside University Health MISP |
$252.73
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$31,212.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$31,212.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$26,010.00
|
| Rate for Payer: United Healthcare All Other HMO |
$26,010.00
|
| Rate for Payer: United Healthcare HMO Rider |
$26,010.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$26,010.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$287.19
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$252.73
|
| Rate for Payer: Vantage Medical Group Senior |
$252.73
|
|
|
LUTETIUM LU-177 VIPIVOTIDE TETRAXETAN 27 MCI/ML (1,000 MBQ/ML) IV SOLN [233901]
|
Facility
IP
|
$52,020.00
|
|
|
Service Code
|
CPT A9607
|
| Hospital Charge Code |
NDG233901
|
|
Hospital Revenue Code
|
344
|
| Min. Negotiated Rate |
$10,404.00 |
| Max. Negotiated Rate |
$46,818.00 |
| Rate for Payer: Blue Shield of California Commercial |
$39,015.00
|
| Rate for Payer: Blue Shield of California EPN |
$27,778.68
|
| Rate for Payer: Cash Price |
$23,409.00
|
| Rate for Payer: Central Health Plan Commercial |
$41,616.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$20,808.00
|
| Rate for Payer: Galaxy Health WC |
$44,217.00
|
| Rate for Payer: Global Benefits Group Commercial |
$31,212.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$46,818.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$34,697.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10,404.00
|
| Rate for Payer: Multiplan Commercial |
$39,015.00
|
| Rate for Payer: Networks By Design Commercial |
$33,813.00
|
| Rate for Payer: Prime Health Services Commercial |
$44,217.00
|
|
|
LYMPHATIC AND OTHER MALIGNANCIES AND NEOPLASMS OF UNCERTAIN BEHAVIOR
|
Facility
IP
|
$22,965.91
|
|
|
Service Code
|
APR-DRG 6944
|
| Min. Negotiated Rate |
$19,272.10 |
| Max. Negotiated Rate |
$22,965.91 |
| Rate for Payer: Adventist Health Medi-Cal |
$19,272.10
|
| Rate for Payer: IEHP medi-cal |
$22,965.91
|
|
|
LYMPHATIC AND OTHER MALIGNANCIES AND NEOPLASMS OF UNCERTAIN BEHAVIOR
|
Facility
IP
|
$7,229.06
|
|
|
Service Code
|
APR-DRG 6941
|
| Min. Negotiated Rate |
$6,066.35 |
| Max. Negotiated Rate |
$7,229.06 |
| Rate for Payer: Adventist Health Medi-Cal |
$6,066.35
|
| Rate for Payer: IEHP medi-cal |
$7,229.06
|
|
|
LYMPHATIC AND OTHER MALIGNANCIES AND NEOPLASMS OF UNCERTAIN BEHAVIOR
|
Facility
IP
|
$9,047.02
|
|
|
Service Code
|
APR-DRG 6942
|
| Min. Negotiated Rate |
$7,591.91 |
| Max. Negotiated Rate |
$9,047.02 |
| Rate for Payer: Adventist Health Medi-Cal |
$7,591.91
|
| Rate for Payer: IEHP medi-cal |
$9,047.02
|
|
|
LYMPHATIC AND OTHER MALIGNANCIES AND NEOPLASMS OF UNCERTAIN BEHAVIOR
|
Facility
IP
|
$13,295.57
|
|
|
Service Code
|
APR-DRG 6943
|
| Min. Negotiated Rate |
$11,157.12 |
| Max. Negotiated Rate |
$13,295.57 |
| Rate for Payer: Adventist Health Medi-Cal |
$11,157.12
|
| Rate for Payer: IEHP medi-cal |
$13,295.57
|
|
|
LYMPHOMA, MYELOMA AND NON-ACUTE LEUKEMIA
|
Facility
IP
|
$19,893.29
|
|
|
Service Code
|
APR-DRG 6913
|
| Min. Negotiated Rate |
$16,693.67 |
| Max. Negotiated Rate |
$19,893.29 |
| Rate for Payer: Adventist Health Medi-Cal |
$16,693.67
|
| Rate for Payer: IEHP medi-cal |
$19,893.29
|
|
|
LYMPHOMA, MYELOMA AND NON-ACUTE LEUKEMIA
|
Facility
IP
|
$37,010.29
|
|
|
Service Code
|
APR-DRG 6914
|
| Min. Negotiated Rate |
$31,057.58 |
| Max. Negotiated Rate |
$37,010.29 |
| Rate for Payer: Adventist Health Medi-Cal |
$31,057.58
|
| Rate for Payer: IEHP medi-cal |
$37,010.29
|
|
|
LYMPHOMA, MYELOMA AND NON-ACUTE LEUKEMIA
|
Facility
IP
|
$13,279.55
|
|
|
Service Code
|
APR-DRG 6912
|
| Min. Negotiated Rate |
$11,143.68 |
| Max. Negotiated Rate |
$13,279.55 |
| Rate for Payer: Adventist Health Medi-Cal |
$11,143.68
|
| Rate for Payer: IEHP medi-cal |
$13,279.55
|
|
|
LYMPHOMA, MYELOMA AND NON-ACUTE LEUKEMIA
|
Facility
IP
|
$10,245.64
|
|
|
Service Code
|
APR-DRG 6911
|
| Min. Negotiated Rate |
$8,597.74 |
| Max. Negotiated Rate |
$10,245.64 |
| Rate for Payer: Adventist Health Medi-Cal |
$8,597.74
|
| Rate for Payer: IEHP medi-cal |
$10,245.64
|
|
|
Lysis or excision of penile post-circumcision adhesions
|
Facility
OP
|
$397,400.00
|
|
|
Service Code
|
CPT 54162
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,544.87 |
| Max. Negotiated Rate |
$397,400.00 |
| Rate for Payer: Adventist Health Medi-Cal |
$2,544.87
|
| Rate for Payer: Aetna of CA HMO/PPO |
$6,248.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3,817.30
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2,799.36
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2,544.87
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$397,400.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,846.00
|
| Rate for Payer: Blue Shield of California Commercial |
$4,121.55
|
| Rate for Payer: Blue Shield of California EPN |
$2,960.28
|
| Rate for Payer: Caremore Medicare Advantage |
$2,544.87
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,817.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,435.57
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$2,544.87
|
| Rate for Payer: EPIC Health Plan Transplant |
$2,544.87
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$4,173.59
|
| Rate for Payer: IEHP medi-cal |
$4,199.04
|
| Rate for Payer: IEHP Medicare Advantage |
$2,544.87
|
| Rate for Payer: Innovage PACE Commercial |
$3,817.30
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,544.87
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3,410.13
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3,410.13
|
| Rate for Payer: Prime Health Services Medicare |
$2,697.56
|
| Rate for Payer: Riverside University Health MISP |
$2,799.36
|
| Rate for Payer: United Healthcare All Other Commercial |
$11,375.00
|
| Rate for Payer: United Healthcare All Other HMO |
$15,354.00
|
| Rate for Payer: United Healthcare HMO Rider |
$9,681.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$8,852.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,817.30
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,799.36
|
| Rate for Payer: Vantage Medical Group Senior |
$2,544.87
|
|
|
MACITENTAN 10 MG TABLET [203952]
|
Facility
OP
|
$447.39
|
|
|
Service Code
|
NDC 66215-501-30
|
| Hospital Charge Code |
ERX203952
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$89.48 |
| Max. Negotiated Rate |
$402.65 |
| Rate for Payer: Aetna of CA HMO/PPO |
$271.70
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$380.28
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$246.06
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$246.06
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$216.63
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$264.32
|
| Rate for Payer: BCBS Transplant Transplant |
$268.43
|
| Rate for Payer: Blue Shield of California Commercial |
$281.41
|
| Rate for Payer: Blue Shield of California EPN |
$218.77
|
| Rate for Payer: Cash Price |
$201.33
|
| Rate for Payer: Central Health Plan Commercial |
$357.91
|
| Rate for Payer: Cigna of CA HMO |
$313.17
|
| Rate for Payer: Cigna of CA PPO |
$313.17
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$380.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$178.96
|
| Rate for Payer: EPIC Health Plan Transplant |
$178.96
|
| Rate for Payer: Galaxy Health WC |
$380.28
|
| Rate for Payer: Global Benefits Group Commercial |
$268.43
|
| Rate for Payer: Health Management Network EPO/PPO |
$402.65
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$335.54
|
| Rate for Payer: IEHP medi-cal |
$156.59
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$298.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$89.48
|
| Rate for Payer: Multiplan Commercial |
$335.54
|
| Rate for Payer: Networks By Design Commercial |
$290.80
|
| Rate for Payer: Prime Health Services Commercial |
$380.28
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$268.43
|
| Rate for Payer: Riverside University Health MISP |
$178.96
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$268.43
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$268.43
|
| Rate for Payer: United Healthcare All Other Commercial |
$223.70
|
| Rate for Payer: United Healthcare All Other HMO |
$223.70
|
| Rate for Payer: United Healthcare HMO Rider |
$223.70
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$223.70
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$380.28
|
| Rate for Payer: Vantage Medical Group Senior |
$380.28
|
|
|
MACITENTAN 10 MG TABLET [203952]
|
Facility
IP
|
$447.39
|
|
|
Service Code
|
NDC 66215-501-30
|
| Hospital Charge Code |
ERX203952
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$89.48 |
| Max. Negotiated Rate |
$402.65 |
| Rate for Payer: Blue Shield of California Commercial |
$335.54
|
| Rate for Payer: Blue Shield of California EPN |
$238.91
|
| Rate for Payer: Cash Price |
$201.33
|
| Rate for Payer: Central Health Plan Commercial |
$357.91
|
| Rate for Payer: Cigna of CA HMO |
$313.17
|
| Rate for Payer: Cigna of CA PPO |
$313.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$178.96
|
| Rate for Payer: Galaxy Health WC |
$380.28
|
| Rate for Payer: Global Benefits Group Commercial |
$268.43
|
| Rate for Payer: Health Management Network EPO/PPO |
$402.65
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$298.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$89.48
|
| Rate for Payer: Multiplan Commercial |
$335.54
|
| Rate for Payer: Networks By Design Commercial |
$290.80
|
| Rate for Payer: Prime Health Services Commercial |
$380.28
|
|
|
MACITENTAN 10 MG TABLET [203952]
|
Facility
IP
|
$447.39
|
|
|
Service Code
|
NDC 66215-501-15
|
| Hospital Charge Code |
ERX203952
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$89.48 |
| Max. Negotiated Rate |
$402.65 |
| Rate for Payer: Blue Shield of California Commercial |
$335.54
|
| Rate for Payer: Blue Shield of California EPN |
$238.91
|
| Rate for Payer: Cash Price |
$201.33
|
| Rate for Payer: Central Health Plan Commercial |
$357.91
|
| Rate for Payer: Cigna of CA HMO |
$313.17
|
| Rate for Payer: Cigna of CA PPO |
$313.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$178.96
|
| Rate for Payer: Galaxy Health WC |
$380.28
|
| Rate for Payer: Global Benefits Group Commercial |
$268.43
|
| Rate for Payer: Health Management Network EPO/PPO |
$402.65
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$298.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$89.48
|
| Rate for Payer: Multiplan Commercial |
$335.54
|
| Rate for Payer: Networks By Design Commercial |
$290.80
|
| Rate for Payer: Prime Health Services Commercial |
$380.28
|
|
|
MACITENTAN 10 MG TABLET [203952]
|
Facility
OP
|
$447.39
|
|
|
Service Code
|
NDC 66215-501-15
|
| Hospital Charge Code |
ERX203952
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$89.48 |
| Max. Negotiated Rate |
$402.65 |
| Rate for Payer: Aetna of CA HMO/PPO |
$271.70
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$380.28
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$246.06
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$246.06
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$216.63
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$264.32
|
| Rate for Payer: BCBS Transplant Transplant |
$268.43
|
| Rate for Payer: Blue Shield of California Commercial |
$281.41
|
| Rate for Payer: Blue Shield of California EPN |
$218.77
|
| Rate for Payer: Cash Price |
$201.33
|
| Rate for Payer: Central Health Plan Commercial |
$357.91
|
| Rate for Payer: Cigna of CA HMO |
$313.17
|
| Rate for Payer: Cigna of CA PPO |
$313.17
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$380.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$178.96
|
| Rate for Payer: EPIC Health Plan Transplant |
$178.96
|
| Rate for Payer: Galaxy Health WC |
$380.28
|
| Rate for Payer: Global Benefits Group Commercial |
$268.43
|
| Rate for Payer: Health Management Network EPO/PPO |
$402.65
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$335.54
|
| Rate for Payer: IEHP medi-cal |
$156.59
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$298.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$89.48
|
| Rate for Payer: Multiplan Commercial |
$335.54
|
| Rate for Payer: Networks By Design Commercial |
$290.80
|
| Rate for Payer: Prime Health Services Commercial |
$380.28
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$268.43
|
| Rate for Payer: Riverside University Health MISP |
$178.96
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$268.43
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$268.43
|
| Rate for Payer: United Healthcare All Other Commercial |
$223.70
|
| Rate for Payer: United Healthcare All Other HMO |
$223.70
|
| Rate for Payer: United Healthcare HMO Rider |
$223.70
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$223.70
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$380.28
|
| Rate for Payer: Vantage Medical Group Senior |
$380.28
|
|
|
MAFENIDE 50 GRAM TOPICAL PACKET [23233]
|
Facility
IP
|
$167.95
|
|
|
Service Code
|
NDC 49884-902-52
|
| Hospital Charge Code |
1743697
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$33.59 |
| Max. Negotiated Rate |
$151.16 |
| Rate for Payer: Blue Shield of California Commercial |
$125.96
|
| Rate for Payer: Blue Shield of California EPN |
$89.69
|
| Rate for Payer: Cash Price |
$75.58
|
| Rate for Payer: Central Health Plan Commercial |
$134.36
|
| Rate for Payer: Cigna of CA HMO |
$117.56
|
| Rate for Payer: Cigna of CA PPO |
$117.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$67.18
|
| Rate for Payer: Galaxy Health WC |
$142.76
|
| Rate for Payer: Global Benefits Group Commercial |
$100.77
|
| Rate for Payer: Health Management Network EPO/PPO |
$151.16
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$112.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$33.59
|
| Rate for Payer: Multiplan Commercial |
$125.96
|
| Rate for Payer: Networks By Design Commercial |
$109.17
|
| Rate for Payer: Prime Health Services Commercial |
$142.76
|
|
|
MAFENIDE 50 GRAM TOPICAL PACKET [23233]
|
Facility
OP
|
$167.95
|
|
|
Service Code
|
NDC 49884-902-52
|
| Hospital Charge Code |
1743697
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$33.59 |
| Max. Negotiated Rate |
$151.16 |
| Rate for Payer: Aetna of CA HMO/PPO |
$102.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$142.76
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$92.37
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$92.37
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$81.32
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$99.22
|
| Rate for Payer: BCBS Transplant Transplant |
$100.77
|
| Rate for Payer: Blue Shield of California Commercial |
$105.64
|
| Rate for Payer: Blue Shield of California EPN |
$82.13
|
| Rate for Payer: Cash Price |
$75.58
|
| Rate for Payer: Central Health Plan Commercial |
$134.36
|
| Rate for Payer: Cigna of CA HMO |
$117.56
|
| Rate for Payer: Cigna of CA PPO |
$117.56
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$142.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$67.18
|
| Rate for Payer: EPIC Health Plan Transplant |
$67.18
|
| Rate for Payer: Galaxy Health WC |
$142.76
|
| Rate for Payer: Global Benefits Group Commercial |
$100.77
|
| Rate for Payer: Health Management Network EPO/PPO |
$151.16
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$125.96
|
| Rate for Payer: IEHP medi-cal |
$58.78
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$112.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$33.59
|
| Rate for Payer: Multiplan Commercial |
$125.96
|
| Rate for Payer: Networks By Design Commercial |
$109.17
|
| Rate for Payer: Prime Health Services Commercial |
$142.76
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$100.77
|
| Rate for Payer: Riverside University Health MISP |
$67.18
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$100.77
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$100.77
|
| Rate for Payer: United Healthcare All Other Commercial |
$83.98
|
| Rate for Payer: United Healthcare All Other HMO |
$83.98
|
| Rate for Payer: United Healthcare HMO Rider |
$83.98
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$83.98
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$142.76
|
| Rate for Payer: Vantage Medical Group Senior |
$142.76
|
|
|
MAFENIDE 85 MG/G TOPICAL CREAM [10478]
|
Facility
IP
|
$1.28
|
|
|
Service Code
|
NDC 51079-623-81
|
| Hospital Charge Code |
NDG10478
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$1.15 |
| Rate for Payer: Blue Shield of California Commercial |
$0.96
|
| Rate for Payer: Blue Shield of California EPN |
$0.68
|
| Rate for Payer: Cash Price |
$0.58
|
| Rate for Payer: Central Health Plan Commercial |
$1.02
|
| Rate for Payer: Cigna of CA HMO |
$0.90
|
| Rate for Payer: Cigna of CA PPO |
$0.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.51
|
| Rate for Payer: Galaxy Health WC |
$1.09
|
| Rate for Payer: Global Benefits Group Commercial |
$0.77
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.26
|
| Rate for Payer: Multiplan Commercial |
$0.96
|
| Rate for Payer: Networks By Design Commercial |
$0.83
|
| Rate for Payer: Prime Health Services Commercial |
$1.09
|
|
|
MAFENIDE 85 MG/G TOPICAL CREAM [10478]
|
Facility
OP
|
$1.28
|
|
|
Service Code
|
NDC 51079-623-81
|
| Hospital Charge Code |
NDG10478
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$1.15 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.78
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.09
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.70
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.70
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.62
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.76
|
| Rate for Payer: BCBS Transplant Transplant |
$0.77
|
| Rate for Payer: Blue Shield of California Commercial |
$0.81
|
| Rate for Payer: Blue Shield of California EPN |
$0.63
|
| Rate for Payer: Cash Price |
$0.58
|
| Rate for Payer: Central Health Plan Commercial |
$1.02
|
| Rate for Payer: Cigna of CA HMO |
$0.90
|
| Rate for Payer: Cigna of CA PPO |
$0.90
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.51
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.51
|
| Rate for Payer: Galaxy Health WC |
$1.09
|
| Rate for Payer: Global Benefits Group Commercial |
$0.77
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.15
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.96
|
| Rate for Payer: IEHP medi-cal |
$0.45
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.26
|
| Rate for Payer: Multiplan Commercial |
$0.96
|
| Rate for Payer: Networks By Design Commercial |
$0.83
|
| Rate for Payer: Prime Health Services Commercial |
$1.09
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.77
|
| Rate for Payer: Riverside University Health MISP |
$0.51
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.77
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.77
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.64
|
| Rate for Payer: United Healthcare All Other HMO |
$0.64
|
| Rate for Payer: United Healthcare HMO Rider |
$0.64
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.64
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.09
|
| Rate for Payer: Vantage Medical Group Senior |
$1.09
|
|
|
MAFENIDE 85 MG/G TOPICAL CREAM [10478]
|
Facility
IP
|
$1.23
|
|
|
Service Code
|
NDC 51079-623-82
|
| Hospital Charge Code |
1743480
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$1.11 |
| Rate for Payer: Blue Shield of California Commercial |
$0.92
|
| Rate for Payer: Blue Shield of California EPN |
$0.66
|
| Rate for Payer: Cash Price |
$0.55
|
| Rate for Payer: Central Health Plan Commercial |
$0.98
|
| Rate for Payer: Cigna of CA HMO |
$0.86
|
| Rate for Payer: Cigna of CA PPO |
$0.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.49
|
| Rate for Payer: Galaxy Health WC |
$1.05
|
| Rate for Payer: Global Benefits Group Commercial |
$0.74
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.25
|
| Rate for Payer: Multiplan Commercial |
$0.92
|
| Rate for Payer: Networks By Design Commercial |
$0.80
|
| Rate for Payer: Prime Health Services Commercial |
$1.05
|
|
|
MAFENIDE 85 MG/G TOPICAL CREAM [10478]
|
Facility
OP
|
$1.23
|
|
|
Service Code
|
NDC 51079-623-82
|
| Hospital Charge Code |
1743480
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$1.11 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.75
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.05
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.68
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.68
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.60
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.73
|
| Rate for Payer: BCBS Transplant Transplant |
$0.74
|
| Rate for Payer: Blue Shield of California Commercial |
$0.77
|
| Rate for Payer: Blue Shield of California EPN |
$0.60
|
| Rate for Payer: Cash Price |
$0.55
|
| Rate for Payer: Central Health Plan Commercial |
$0.98
|
| Rate for Payer: Cigna of CA HMO |
$0.86
|
| Rate for Payer: Cigna of CA PPO |
$0.86
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.49
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.49
|
| Rate for Payer: Galaxy Health WC |
$1.05
|
| Rate for Payer: Global Benefits Group Commercial |
$0.74
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.11
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.92
|
| Rate for Payer: IEHP medi-cal |
$0.43
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.25
|
| Rate for Payer: Multiplan Commercial |
$0.92
|
| Rate for Payer: Networks By Design Commercial |
$0.80
|
| Rate for Payer: Prime Health Services Commercial |
$1.05
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.74
|
| Rate for Payer: Riverside University Health MISP |
$0.49
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.74
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.74
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.62
|
| Rate for Payer: United Healthcare All Other HMO |
$0.62
|
| Rate for Payer: United Healthcare HMO Rider |
$0.62
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.62
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.05
|
| Rate for Payer: Vantage Medical Group Senior |
$1.05
|
|
|
MAGNESIUM 64 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE [120162]
|
Facility
IP
|
$0.10
|
|
|
Service Code
|
NDC 6858500575
|
| Hospital Charge Code |
1712587
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Blue Shield of California Commercial |
$0.08
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Central Health Plan Commercial |
$0.08
|
| Rate for Payer: Cigna of CA HMO |
$0.07
|
| Rate for Payer: Cigna of CA PPO |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.09
|
| Rate for Payer: Global Benefits Group Commercial |
$0.06
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: Networks By Design Commercial |
$0.07
|
| Rate for Payer: Prime Health Services Commercial |
$0.09
|
|
|
MAGNESIUM 64 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE [120162]
|
Facility
IP
|
$0.10
|
|
|
Service Code
|
NDC 1000670013
|
| Hospital Charge Code |
1712587
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Blue Shield of California Commercial |
$0.08
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Central Health Plan Commercial |
$0.08
|
| Rate for Payer: Cigna of CA HMO |
$0.07
|
| Rate for Payer: Cigna of CA PPO |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.09
|
| Rate for Payer: Global Benefits Group Commercial |
$0.06
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: Networks By Design Commercial |
$0.07
|
| Rate for Payer: Prime Health Services Commercial |
$0.09
|
|
|
MAGNESIUM 64 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE [120162]
|
Facility
OP
|
$0.10
|
|
|
Service Code
|
NDC 6858500575
|
| Hospital Charge Code |
1712587
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.06
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.06
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.06
|
| Rate for Payer: BCBS Transplant Transplant |
$0.06
|
| Rate for Payer: Blue Shield of California Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Central Health Plan Commercial |
$0.08
|
| Rate for Payer: Cigna of CA HMO |
$0.07
|
| Rate for Payer: Cigna of CA PPO |
$0.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.09
|
| Rate for Payer: Global Benefits Group Commercial |
$0.06
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.09
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.08
|
| Rate for Payer: IEHP medi-cal |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: Networks By Design Commercial |
$0.07
|
| Rate for Payer: Prime Health Services Commercial |
$0.09
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.06
|
| Rate for Payer: Riverside University Health MISP |
$0.04
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.06
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.06
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.05
|
| Rate for Payer: United Healthcare All Other HMO |
$0.05
|
| Rate for Payer: United Healthcare HMO Rider |
$0.05
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Vantage Medical Group Senior |
$0.09
|
|
|
MAGNESIUM 64 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE [120162]
|
Facility
OP
|
$0.10
|
|
|
Service Code
|
NDC 1000670013
|
| Hospital Charge Code |
1712587
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.06
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.06
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.06
|
| Rate for Payer: BCBS Transplant Transplant |
$0.06
|
| Rate for Payer: Blue Shield of California Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Central Health Plan Commercial |
$0.08
|
| Rate for Payer: Cigna of CA HMO |
$0.07
|
| Rate for Payer: Cigna of CA PPO |
$0.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.09
|
| Rate for Payer: Global Benefits Group Commercial |
$0.06
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.09
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.08
|
| Rate for Payer: IEHP medi-cal |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: Networks By Design Commercial |
$0.07
|
| Rate for Payer: Prime Health Services Commercial |
$0.09
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.06
|
| Rate for Payer: Riverside University Health MISP |
$0.04
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.06
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.06
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.05
|
| Rate for Payer: United Healthcare All Other HMO |
$0.05
|
| Rate for Payer: United Healthcare HMO Rider |
$0.05
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Vantage Medical Group Senior |
$0.09
|
|
