|
C.I. ACID BLUE 90 0.025 % INTRAOCULAR SYRINGE [227971]
|
Facility
OP
|
$352.80
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
ERX227971
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$70.56 |
| Max. Negotiated Rate |
$317.52 |
| Rate for Payer: Aetna of CA HMO/PPO |
$214.26
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$299.88
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$194.04
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$194.04
|
| Rate for Payer: BCBS Transplant Transplant |
$211.68
|
| Rate for Payer: Blue Shield of California Commercial |
$221.91
|
| Rate for Payer: Blue Shield of California EPN |
$172.52
|
| Rate for Payer: Cash Price |
$158.76
|
| Rate for Payer: Cash Price |
$158.76
|
| Rate for Payer: Central Health Plan Commercial |
$282.24
|
| Rate for Payer: Cigna of CA HMO |
$246.96
|
| Rate for Payer: Cigna of CA PPO |
$246.96
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$299.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$141.12
|
| Rate for Payer: EPIC Health Plan Transplant |
$141.12
|
| Rate for Payer: Galaxy Health WC |
$299.88
|
| Rate for Payer: Global Benefits Group Commercial |
$211.68
|
| Rate for Payer: Health Management Network EPO/PPO |
$317.52
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$264.60
|
| Rate for Payer: IEHP medi-cal |
$123.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$235.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$70.56
|
| Rate for Payer: Multiplan Commercial |
$264.60
|
| Rate for Payer: Networks By Design Commercial |
$176.40
|
| Rate for Payer: Prime Health Services Commercial |
$299.88
|
| Rate for Payer: Riverside University Health MISP |
$141.12
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$211.68
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$211.68
|
| Rate for Payer: United Healthcare All Other Commercial |
$176.40
|
| Rate for Payer: United Healthcare All Other HMO |
$176.40
|
| Rate for Payer: United Healthcare HMO Rider |
$176.40
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$176.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$299.88
|
| Rate for Payer: Vantage Medical Group Senior |
$299.88
|
|
|
C.I. ACID BLUE 90 0.025 % INTRAOCULAR SYRINGE [227971]
|
Facility
IP
|
$352.80
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
ERX227971
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$70.56 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$264.60
|
| Rate for Payer: Blue Shield of California EPN |
$188.40
|
| Rate for Payer: Cash Price |
$158.76
|
| Rate for Payer: Cash Price |
$158.76
|
| Rate for Payer: Central Health Plan Commercial |
$282.24
|
| Rate for Payer: Cigna of CA HMO |
$246.96
|
| Rate for Payer: Cigna of CA PPO |
$246.96
|
| Rate for Payer: EPIC Health Plan Commercial |
$141.12
|
| Rate for Payer: EPIC Health Plan Transplant |
$141.12
|
| Rate for Payer: Galaxy Health WC |
$299.88
|
| Rate for Payer: Global Benefits Group Commercial |
$211.68
|
| Rate for Payer: Health Management Network EPO/PPO |
$317.52
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$235.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$70.56
|
| Rate for Payer: Multiplan Commercial |
$264.60
|
| Rate for Payer: Networks By Design Commercial |
$176.40
|
| Rate for Payer: Prime Health Services Commercial |
$299.88
|
|
|
CICLOPIROX 0.77 % TOPICAL CREAM [9598]
|
Facility
OP
|
$1.08
|
|
|
Service Code
|
NDC 45802-138-11
|
| Hospital Charge Code |
1743680
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.66
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.92
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.59
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.59
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.52
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.64
|
| Rate for Payer: BCBS Transplant Transplant |
$0.65
|
| Rate for Payer: Blue Shield of California Commercial |
$0.68
|
| Rate for Payer: Blue Shield of California EPN |
$0.53
|
| Rate for Payer: Cash Price |
$0.49
|
| Rate for Payer: Central Health Plan Commercial |
$0.86
|
| Rate for Payer: Cigna of CA HMO |
$0.76
|
| Rate for Payer: Cigna of CA PPO |
$0.76
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.43
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.43
|
| Rate for Payer: Galaxy Health WC |
$0.92
|
| Rate for Payer: Global Benefits Group Commercial |
$0.65
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.97
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.81
|
| Rate for Payer: IEHP medi-cal |
$0.38
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.22
|
| Rate for Payer: Multiplan Commercial |
$0.81
|
| Rate for Payer: Networks By Design Commercial |
$0.70
|
| Rate for Payer: Prime Health Services Commercial |
$0.92
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.65
|
| Rate for Payer: Riverside University Health MISP |
$0.43
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.65
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.65
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.54
|
| Rate for Payer: United Healthcare All Other HMO |
$0.54
|
| Rate for Payer: United Healthcare HMO Rider |
$0.54
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.54
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.92
|
| Rate for Payer: Vantage Medical Group Senior |
$0.92
|
|
|
CICLOPIROX 0.77 % TOPICAL CREAM [9598]
|
Facility
IP
|
$1.49
|
|
|
Service Code
|
NDC 51672-1318-1
|
| Hospital Charge Code |
NDG9598
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$1.12
|
| Rate for Payer: Blue Shield of California EPN |
$0.80
|
| Rate for Payer: Cash Price |
$0.67
|
| Rate for Payer: Cash Price |
$0.67
|
| Rate for Payer: Central Health Plan Commercial |
$1.19
|
| Rate for Payer: Cigna of CA HMO |
$1.04
|
| Rate for Payer: Cigna of CA PPO |
$1.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.60
|
| Rate for Payer: Galaxy Health WC |
$1.27
|
| Rate for Payer: Global Benefits Group Commercial |
$0.89
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.34
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Multiplan Commercial |
$1.12
|
| Rate for Payer: Networks By Design Commercial |
$0.97
|
| Rate for Payer: Prime Health Services Commercial |
$1.27
|
|
|
CICLOPIROX 0.77 % TOPICAL CREAM [9598]
|
Facility
OP
|
$1.23
|
|
|
Service Code
|
NDC 68462-297-17
|
| Hospital Charge Code |
NDG9598
|
|
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
|
|
|
CICLOPIROX 0.77 % TOPICAL CREAM [9598]
|
Facility
IP
|
$1.23
|
|
|
Service Code
|
NDC 68462-297-17
|
| Hospital Charge Code |
NDG9598
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| 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: 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
|
|
|
CICLOPIROX 0.77 % TOPICAL CREAM [9598]
|
Facility
IP
|
$1.08
|
|
|
Service Code
|
NDC 45802-138-11
|
| Hospital Charge Code |
1743680
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$0.81
|
| Rate for Payer: Blue Shield of California EPN |
$0.58
|
| Rate for Payer: Cash Price |
$0.49
|
| Rate for Payer: Cash Price |
$0.49
|
| Rate for Payer: Central Health Plan Commercial |
$0.86
|
| Rate for Payer: Cigna of CA HMO |
$0.76
|
| Rate for Payer: Cigna of CA PPO |
$0.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.43
|
| Rate for Payer: Galaxy Health WC |
$0.92
|
| Rate for Payer: Global Benefits Group Commercial |
$0.65
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.97
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.22
|
| Rate for Payer: Multiplan Commercial |
$0.81
|
| Rate for Payer: Networks By Design Commercial |
$0.70
|
| Rate for Payer: Prime Health Services Commercial |
$0.92
|
|
|
CICLOPIROX 0.77 % TOPICAL CREAM [9598]
|
Facility
OP
|
$1.49
|
|
|
Service Code
|
NDC 51672-1318-1
|
| Hospital Charge Code |
NDG9598
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$1.34 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.90
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.27
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.82
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.82
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.72
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.88
|
| Rate for Payer: BCBS Transplant Transplant |
$0.89
|
| Rate for Payer: Blue Shield of California Commercial |
$0.94
|
| Rate for Payer: Blue Shield of California EPN |
$0.73
|
| Rate for Payer: Cash Price |
$0.67
|
| Rate for Payer: Central Health Plan Commercial |
$1.19
|
| Rate for Payer: Cigna of CA HMO |
$1.04
|
| Rate for Payer: Cigna of CA PPO |
$1.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.60
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.60
|
| Rate for Payer: Galaxy Health WC |
$1.27
|
| Rate for Payer: Global Benefits Group Commercial |
$0.89
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.34
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1.12
|
| Rate for Payer: IEHP medi-cal |
$0.52
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Multiplan Commercial |
$1.12
|
| Rate for Payer: Networks By Design Commercial |
$0.97
|
| Rate for Payer: Prime Health Services Commercial |
$1.27
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.89
|
| Rate for Payer: Riverside University Health MISP |
$0.60
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.89
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.89
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.75
|
| Rate for Payer: United Healthcare All Other HMO |
$0.75
|
| Rate for Payer: United Healthcare HMO Rider |
$0.75
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.75
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.27
|
| Rate for Payer: Vantage Medical Group Senior |
$1.27
|
|
|
CICLOPIROX 8 % TOPICAL SOLUTION [27158]
|
Facility
IP
|
$6.76
|
|
|
Service Code
|
NDC 50383-419-06
|
| Hospital Charge Code |
1743748
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.35 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$5.07
|
| Rate for Payer: Blue Shield of California EPN |
$3.61
|
| Rate for Payer: Cash Price |
$3.04
|
| Rate for Payer: Cash Price |
$3.04
|
| Rate for Payer: Central Health Plan Commercial |
$5.41
|
| Rate for Payer: Cigna of CA HMO |
$4.73
|
| Rate for Payer: Cigna of CA PPO |
$4.73
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.70
|
| Rate for Payer: Galaxy Health WC |
$5.75
|
| Rate for Payer: Global Benefits Group Commercial |
$4.06
|
| Rate for Payer: Health Management Network EPO/PPO |
$6.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.35
|
| Rate for Payer: Multiplan Commercial |
$5.07
|
| Rate for Payer: Networks By Design Commercial |
$4.39
|
| Rate for Payer: Prime Health Services Commercial |
$5.75
|
|
|
CICLOPIROX 8 % TOPICAL SOLUTION [27158]
|
Facility
OP
|
$6.76
|
|
|
Service Code
|
NDC 50383-419-06
|
| Hospital Charge Code |
1743748
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.35 |
| Max. Negotiated Rate |
$6.08 |
| Rate for Payer: Aetna of CA HMO/PPO |
$4.11
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$5.75
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.72
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3.72
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$3.27
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.99
|
| Rate for Payer: BCBS Transplant Transplant |
$4.06
|
| Rate for Payer: Blue Shield of California Commercial |
$4.25
|
| Rate for Payer: Blue Shield of California EPN |
$3.31
|
| Rate for Payer: Cash Price |
$3.04
|
| Rate for Payer: Central Health Plan Commercial |
$5.41
|
| Rate for Payer: Cigna of CA HMO |
$4.73
|
| Rate for Payer: Cigna of CA PPO |
$4.73
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.70
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.70
|
| Rate for Payer: Galaxy Health WC |
$5.75
|
| Rate for Payer: Global Benefits Group Commercial |
$4.06
|
| Rate for Payer: Health Management Network EPO/PPO |
$6.08
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$5.07
|
| Rate for Payer: IEHP medi-cal |
$2.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.35
|
| Rate for Payer: Multiplan Commercial |
$5.07
|
| Rate for Payer: Networks By Design Commercial |
$4.39
|
| Rate for Payer: Prime Health Services Commercial |
$5.75
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$4.06
|
| Rate for Payer: Riverside University Health MISP |
$2.70
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$4.06
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$4.06
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.38
|
| Rate for Payer: United Healthcare All Other HMO |
$3.38
|
| Rate for Payer: United Healthcare HMO Rider |
$3.38
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.38
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.75
|
| Rate for Payer: Vantage Medical Group Senior |
$5.75
|
|
|
CICLOPIROX 8 % TOPICAL SOLUTION [27158]
|
Facility
IP
|
$5.82
|
|
|
Service Code
|
NDC 0713-0317-88
|
| Hospital Charge Code |
1743748
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.16 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$4.36
|
| Rate for Payer: Blue Shield of California EPN |
$3.11
|
| Rate for Payer: Cash Price |
$2.62
|
| Rate for Payer: Cash Price |
$2.62
|
| Rate for Payer: Central Health Plan Commercial |
$4.66
|
| Rate for Payer: Cigna of CA HMO |
$4.07
|
| Rate for Payer: Cigna of CA PPO |
$4.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.33
|
| Rate for Payer: Galaxy Health WC |
$4.95
|
| Rate for Payer: Global Benefits Group Commercial |
$3.49
|
| Rate for Payer: Health Management Network EPO/PPO |
$5.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.16
|
| Rate for Payer: Multiplan Commercial |
$4.36
|
| Rate for Payer: Networks By Design Commercial |
$3.78
|
| Rate for Payer: Prime Health Services Commercial |
$4.95
|
|
|
CICLOPIROX 8 % TOPICAL SOLUTION [27158]
|
Facility
OP
|
$5.82
|
|
|
Service Code
|
NDC 0713-0317-88
|
| Hospital Charge Code |
1743748
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.16 |
| Max. Negotiated Rate |
$5.24 |
| Rate for Payer: Aetna of CA HMO/PPO |
$3.53
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$4.95
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.20
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3.20
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$2.82
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.44
|
| Rate for Payer: BCBS Transplant Transplant |
$3.49
|
| Rate for Payer: Blue Shield of California Commercial |
$3.66
|
| Rate for Payer: Blue Shield of California EPN |
$2.85
|
| Rate for Payer: Cash Price |
$2.62
|
| Rate for Payer: Central Health Plan Commercial |
$4.66
|
| Rate for Payer: Cigna of CA HMO |
$4.07
|
| Rate for Payer: Cigna of CA PPO |
$4.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.33
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.33
|
| Rate for Payer: Galaxy Health WC |
$4.95
|
| Rate for Payer: Global Benefits Group Commercial |
$3.49
|
| Rate for Payer: Health Management Network EPO/PPO |
$5.24
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$4.36
|
| Rate for Payer: IEHP medi-cal |
$2.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.16
|
| Rate for Payer: Multiplan Commercial |
$4.36
|
| Rate for Payer: Networks By Design Commercial |
$3.78
|
| Rate for Payer: Prime Health Services Commercial |
$4.95
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$3.49
|
| Rate for Payer: Riverside University Health MISP |
$2.33
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.49
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.49
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.91
|
| Rate for Payer: United Healthcare All Other HMO |
$2.91
|
| Rate for Payer: United Healthcare HMO Rider |
$2.91
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.91
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.95
|
| Rate for Payer: Vantage Medical Group Senior |
$4.95
|
|
|
CIDOFOVIR 10 MG/ML TOPICAL [4082503]
|
Facility
IP
|
$24.48
|
|
|
Service Code
|
NDC 9994-0825-03
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.90 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$18.36
|
| Rate for Payer: Blue Shield of California EPN |
$13.07
|
| Rate for Payer: Cash Price |
$11.02
|
| Rate for Payer: Cash Price |
$11.02
|
| Rate for Payer: Central Health Plan Commercial |
$19.58
|
| Rate for Payer: Cigna of CA HMO |
$17.14
|
| Rate for Payer: Cigna of CA PPO |
$17.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.79
|
| Rate for Payer: EPIC Health Plan Transplant |
$9.79
|
| Rate for Payer: Galaxy Health WC |
$20.81
|
| Rate for Payer: Global Benefits Group Commercial |
$14.69
|
| Rate for Payer: Health Management Network EPO/PPO |
$22.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$16.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.90
|
| Rate for Payer: Multiplan Commercial |
$18.36
|
| Rate for Payer: Networks By Design Commercial |
$12.24
|
| Rate for Payer: Prime Health Services Commercial |
$20.81
|
|
|
CIDOFOVIR 10 MG/ML TOPICAL [4082503]
|
Facility
OP
|
$24.48
|
|
|
Service Code
|
NDC 9994-0825-03
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.90 |
| Max. Negotiated Rate |
$22.03 |
| Rate for Payer: Aetna of CA HMO/PPO |
$14.87
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$20.81
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$13.46
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$13.46
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$11.85
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$14.46
|
| Rate for Payer: BCBS Transplant Transplant |
$14.69
|
| Rate for Payer: Blue Shield of California Commercial |
$15.40
|
| Rate for Payer: Blue Shield of California EPN |
$11.97
|
| Rate for Payer: Cash Price |
$11.02
|
| Rate for Payer: Cash Price |
$11.02
|
| Rate for Payer: Central Health Plan Commercial |
$19.58
|
| Rate for Payer: Cigna of CA HMO |
$17.14
|
| Rate for Payer: Cigna of CA PPO |
$17.14
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$20.81
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.79
|
| Rate for Payer: EPIC Health Plan Transplant |
$9.79
|
| Rate for Payer: Galaxy Health WC |
$20.81
|
| Rate for Payer: Global Benefits Group Commercial |
$14.69
|
| Rate for Payer: Health Management Network EPO/PPO |
$22.03
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$18.36
|
| Rate for Payer: IEHP medi-cal |
$8.57
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$16.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.90
|
| Rate for Payer: Multiplan Commercial |
$18.36
|
| Rate for Payer: Networks By Design Commercial |
$12.24
|
| Rate for Payer: Prime Health Services Commercial |
$20.81
|
| Rate for Payer: Riverside University Health MISP |
$9.79
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$14.69
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$14.69
|
| Rate for Payer: United Healthcare All Other Commercial |
$12.24
|
| Rate for Payer: United Healthcare All Other HMO |
$12.24
|
| Rate for Payer: United Healthcare HMO Rider |
$12.24
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$12.24
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$20.81
|
| Rate for Payer: Vantage Medical Group Senior |
$20.81
|
|
|
CIDOFOVIR 15 MG/ML TOPICAL [4081161]
|
Facility
OP
|
$36.54
|
|
|
Service Code
|
NDC 99994-811-61
|
| Hospital Charge Code |
NDC4081161
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.31 |
| Max. Negotiated Rate |
$32.89 |
| Rate for Payer: Aetna of CA HMO/PPO |
$22.19
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$31.06
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$20.10
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$20.10
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$17.69
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$21.59
|
| Rate for Payer: BCBS Transplant Transplant |
$21.92
|
| Rate for Payer: Blue Shield of California Commercial |
$22.98
|
| Rate for Payer: Blue Shield of California EPN |
$17.87
|
| Rate for Payer: Cash Price |
$16.44
|
| Rate for Payer: Cash Price |
$16.44
|
| Rate for Payer: Central Health Plan Commercial |
$29.23
|
| Rate for Payer: Cigna of CA HMO |
$25.58
|
| Rate for Payer: Cigna of CA PPO |
$25.58
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$31.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.62
|
| Rate for Payer: EPIC Health Plan Transplant |
$14.62
|
| Rate for Payer: Galaxy Health WC |
$31.06
|
| Rate for Payer: Global Benefits Group Commercial |
$21.92
|
| Rate for Payer: Health Management Network EPO/PPO |
$32.89
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$27.40
|
| Rate for Payer: IEHP medi-cal |
$12.79
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$24.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.31
|
| Rate for Payer: Multiplan Commercial |
$27.40
|
| Rate for Payer: Networks By Design Commercial |
$18.27
|
| Rate for Payer: Prime Health Services Commercial |
$31.06
|
| Rate for Payer: Riverside University Health MISP |
$14.62
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$21.92
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$21.92
|
| Rate for Payer: United Healthcare All Other Commercial |
$18.27
|
| Rate for Payer: United Healthcare All Other HMO |
$18.27
|
| Rate for Payer: United Healthcare HMO Rider |
$18.27
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$18.27
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$31.06
|
| Rate for Payer: Vantage Medical Group Senior |
$31.06
|
|
|
CIDOFOVIR 15 MG/ML TOPICAL [4081161]
|
Facility
IP
|
$36.54
|
|
|
Service Code
|
NDC 99994-811-61
|
| Hospital Charge Code |
NDC4081161
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.31 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$27.40
|
| Rate for Payer: Blue Shield of California EPN |
$19.51
|
| Rate for Payer: Cash Price |
$16.44
|
| Rate for Payer: Cash Price |
$16.44
|
| Rate for Payer: Central Health Plan Commercial |
$29.23
|
| Rate for Payer: Cigna of CA HMO |
$25.58
|
| Rate for Payer: Cigna of CA PPO |
$25.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.62
|
| Rate for Payer: EPIC Health Plan Transplant |
$14.62
|
| Rate for Payer: Galaxy Health WC |
$31.06
|
| Rate for Payer: Global Benefits Group Commercial |
$21.92
|
| Rate for Payer: Health Management Network EPO/PPO |
$32.89
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$24.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.31
|
| Rate for Payer: Multiplan Commercial |
$27.40
|
| Rate for Payer: Networks By Design Commercial |
$18.27
|
| Rate for Payer: Prime Health Services Commercial |
$31.06
|
|
|
CIDOFOVIR 1 MG/ML TOPICAL [4081092]
|
Facility
OP
|
$36.54
|
|
|
Service Code
|
NDC 99994-811-92
|
| Hospital Charge Code |
NDC4081092
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.31 |
| Max. Negotiated Rate |
$32.89 |
| Rate for Payer: Aetna of CA HMO/PPO |
$22.19
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$31.06
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$20.10
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$20.10
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$17.69
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$21.59
|
| Rate for Payer: BCBS Transplant Transplant |
$21.92
|
| Rate for Payer: Blue Shield of California Commercial |
$22.98
|
| Rate for Payer: Blue Shield of California EPN |
$17.87
|
| Rate for Payer: Cash Price |
$16.44
|
| Rate for Payer: Cash Price |
$16.44
|
| Rate for Payer: Central Health Plan Commercial |
$29.23
|
| Rate for Payer: Cigna of CA HMO |
$25.58
|
| Rate for Payer: Cigna of CA PPO |
$25.58
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$31.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.62
|
| Rate for Payer: EPIC Health Plan Transplant |
$14.62
|
| Rate for Payer: Galaxy Health WC |
$31.06
|
| Rate for Payer: Global Benefits Group Commercial |
$21.92
|
| Rate for Payer: Health Management Network EPO/PPO |
$32.89
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$27.40
|
| Rate for Payer: IEHP medi-cal |
$12.79
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$24.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.31
|
| Rate for Payer: Multiplan Commercial |
$27.40
|
| Rate for Payer: Networks By Design Commercial |
$18.27
|
| Rate for Payer: Prime Health Services Commercial |
$31.06
|
| Rate for Payer: Riverside University Health MISP |
$14.62
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$21.92
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$21.92
|
| Rate for Payer: United Healthcare All Other Commercial |
$18.27
|
| Rate for Payer: United Healthcare All Other HMO |
$18.27
|
| Rate for Payer: United Healthcare HMO Rider |
$18.27
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$18.27
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$31.06
|
| Rate for Payer: Vantage Medical Group Senior |
$31.06
|
|
|
CIDOFOVIR 1 MG/ML TOPICAL [4081092]
|
Facility
IP
|
$36.54
|
|
|
Service Code
|
NDC 99994-811-92
|
| Hospital Charge Code |
NDC4081092
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.31 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$27.40
|
| Rate for Payer: Blue Shield of California EPN |
$19.51
|
| Rate for Payer: Cash Price |
$16.44
|
| Rate for Payer: Cash Price |
$16.44
|
| Rate for Payer: Central Health Plan Commercial |
$29.23
|
| Rate for Payer: Cigna of CA HMO |
$25.58
|
| Rate for Payer: Cigna of CA PPO |
$25.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.62
|
| Rate for Payer: EPIC Health Plan Transplant |
$14.62
|
| Rate for Payer: Galaxy Health WC |
$31.06
|
| Rate for Payer: Global Benefits Group Commercial |
$21.92
|
| Rate for Payer: Health Management Network EPO/PPO |
$32.89
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$24.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.31
|
| Rate for Payer: Multiplan Commercial |
$27.40
|
| Rate for Payer: Networks By Design Commercial |
$18.27
|
| Rate for Payer: Prime Health Services Commercial |
$31.06
|
|
|
CIDOFOVIR 3 MG/ML TOPICAL [4081091]
|
Facility
IP
|
$36.54
|
|
|
Service Code
|
NDC 99994-811-91
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.31 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$27.40
|
| Rate for Payer: Blue Shield of California EPN |
$19.51
|
| Rate for Payer: Cash Price |
$16.44
|
| Rate for Payer: Cash Price |
$16.44
|
| Rate for Payer: Central Health Plan Commercial |
$29.23
|
| Rate for Payer: Cigna of CA HMO |
$25.58
|
| Rate for Payer: Cigna of CA PPO |
$25.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.62
|
| Rate for Payer: EPIC Health Plan Transplant |
$14.62
|
| Rate for Payer: Galaxy Health WC |
$31.06
|
| Rate for Payer: Global Benefits Group Commercial |
$21.92
|
| Rate for Payer: Health Management Network EPO/PPO |
$32.89
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$24.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.31
|
| Rate for Payer: Multiplan Commercial |
$27.40
|
| Rate for Payer: Networks By Design Commercial |
$18.27
|
| Rate for Payer: Prime Health Services Commercial |
$31.06
|
|
|
CIDOFOVIR 3 MG/ML TOPICAL [4081091]
|
Facility
OP
|
$36.54
|
|
|
Service Code
|
NDC 99994-811-91
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.31 |
| Max. Negotiated Rate |
$32.89 |
| Rate for Payer: Aetna of CA HMO/PPO |
$22.19
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$31.06
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$20.10
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$20.10
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$17.69
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$21.59
|
| Rate for Payer: BCBS Transplant Transplant |
$21.92
|
| Rate for Payer: Blue Shield of California Commercial |
$22.98
|
| Rate for Payer: Blue Shield of California EPN |
$17.87
|
| Rate for Payer: Cash Price |
$16.44
|
| Rate for Payer: Cash Price |
$16.44
|
| Rate for Payer: Central Health Plan Commercial |
$29.23
|
| Rate for Payer: Cigna of CA HMO |
$25.58
|
| Rate for Payer: Cigna of CA PPO |
$25.58
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$31.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.62
|
| Rate for Payer: EPIC Health Plan Transplant |
$14.62
|
| Rate for Payer: Galaxy Health WC |
$31.06
|
| Rate for Payer: Global Benefits Group Commercial |
$21.92
|
| Rate for Payer: Health Management Network EPO/PPO |
$32.89
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$27.40
|
| Rate for Payer: IEHP medi-cal |
$12.79
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$24.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.31
|
| Rate for Payer: Multiplan Commercial |
$27.40
|
| Rate for Payer: Networks By Design Commercial |
$18.27
|
| Rate for Payer: Prime Health Services Commercial |
$31.06
|
| Rate for Payer: Riverside University Health MISP |
$14.62
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$21.92
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$21.92
|
| Rate for Payer: United Healthcare All Other Commercial |
$18.27
|
| Rate for Payer: United Healthcare All Other HMO |
$18.27
|
| Rate for Payer: United Healthcare HMO Rider |
$18.27
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$18.27
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$31.06
|
| Rate for Payer: Vantage Medical Group Senior |
$31.06
|
|
|
CIDOFOVIR 5 MG/ML TOPICAL [4081159]
|
Facility
OP
|
$36.54
|
|
|
Service Code
|
NDC 99994-811-59
|
| Hospital Charge Code |
NDC4081159
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$7.31 |
| Max. Negotiated Rate |
$32.89 |
| Rate for Payer: Aetna of CA HMO/PPO |
$22.19
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$31.06
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$20.10
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$20.10
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$17.69
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$21.59
|
| Rate for Payer: BCBS Transplant Transplant |
$21.92
|
| Rate for Payer: Blue Shield of California Commercial |
$22.98
|
| Rate for Payer: Blue Shield of California EPN |
$17.87
|
| Rate for Payer: Cash Price |
$16.44
|
| Rate for Payer: Central Health Plan Commercial |
$29.23
|
| Rate for Payer: Cigna of CA HMO |
$25.58
|
| Rate for Payer: Cigna of CA PPO |
$25.58
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$31.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.62
|
| Rate for Payer: EPIC Health Plan Transplant |
$14.62
|
| Rate for Payer: Galaxy Health WC |
$31.06
|
| Rate for Payer: Global Benefits Group Commercial |
$21.92
|
| Rate for Payer: Health Management Network EPO/PPO |
$32.89
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$27.40
|
| Rate for Payer: IEHP medi-cal |
$12.79
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$24.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.31
|
| Rate for Payer: Multiplan Commercial |
$27.40
|
| Rate for Payer: Networks By Design Commercial |
$23.75
|
| Rate for Payer: Prime Health Services Commercial |
$31.06
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$21.92
|
| Rate for Payer: Riverside University Health MISP |
$14.62
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$21.92
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$21.92
|
| Rate for Payer: United Healthcare All Other Commercial |
$18.27
|
| Rate for Payer: United Healthcare All Other HMO |
$18.27
|
| Rate for Payer: United Healthcare HMO Rider |
$18.27
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$18.27
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$31.06
|
| Rate for Payer: Vantage Medical Group Senior |
$31.06
|
|
|
CIDOFOVIR 5 MG/ML TOPICAL [4081159]
|
Facility
IP
|
$36.54
|
|
|
Service Code
|
NDC 99994-811-59
|
| Hospital Charge Code |
NDC4081159
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$7.31 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$27.40
|
| Rate for Payer: Blue Shield of California EPN |
$19.51
|
| Rate for Payer: Cash Price |
$16.44
|
| Rate for Payer: Cash Price |
$16.44
|
| Rate for Payer: Central Health Plan Commercial |
$29.23
|
| Rate for Payer: Cigna of CA HMO |
$25.58
|
| Rate for Payer: Cigna of CA PPO |
$25.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.62
|
| Rate for Payer: Galaxy Health WC |
$31.06
|
| Rate for Payer: Global Benefits Group Commercial |
$21.92
|
| Rate for Payer: Health Management Network EPO/PPO |
$32.89
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$24.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.31
|
| Rate for Payer: Multiplan Commercial |
$27.40
|
| Rate for Payer: Networks By Design Commercial |
$23.75
|
| Rate for Payer: Prime Health Services Commercial |
$31.06
|
|
|
CIDOFOVIR 75 MG/ML INTRAVENOUS SOLUTION [17378]
|
Facility
IP
|
$177.60
|
|
|
Service Code
|
CPT J0740
|
| Hospital Charge Code |
1757059
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$35.52 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$133.20
|
| Rate for Payer: Blue Shield of California EPN |
$94.84
|
| Rate for Payer: Cash Price |
$79.92
|
| Rate for Payer: Cash Price |
$79.92
|
| Rate for Payer: Central Health Plan Commercial |
$142.08
|
| Rate for Payer: Cigna of CA HMO |
$124.32
|
| Rate for Payer: Cigna of CA PPO |
$124.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$71.04
|
| Rate for Payer: EPIC Health Plan Transplant |
$71.04
|
| Rate for Payer: Galaxy Health WC |
$150.96
|
| Rate for Payer: Global Benefits Group Commercial |
$106.56
|
| Rate for Payer: Health Management Network EPO/PPO |
$159.84
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$118.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$35.52
|
| Rate for Payer: Multiplan Commercial |
$133.20
|
| Rate for Payer: Networks By Design Commercial |
$88.80
|
| Rate for Payer: Prime Health Services Commercial |
$150.96
|
|
|
CIDOFOVIR 75 MG/ML INTRAVENOUS SOLUTION [17378]
|
Facility
OP
|
$177.60
|
|
|
Service Code
|
CPT J0740
|
| Hospital Charge Code |
1757059
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$35.52 |
| Max. Negotiated Rate |
$3,434.34 |
| Rate for Payer: Adventist Health Medi-Cal |
$554.19
|
| Rate for Payer: Aetna of CA HMO/PPO |
$3,434.34
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$692.74
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$609.61
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$609.61
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1,395.38
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,527.79
|
| Rate for Payer: BCBS Transplant Transplant |
$106.56
|
| Rate for Payer: Blue Shield of California Commercial |
$1,140.95
|
| Rate for Payer: Blue Shield of California EPN |
$1,037.23
|
| Rate for Payer: Caremore Medicare Advantage |
$554.19
|
| Rate for Payer: Cash Price |
$79.92
|
| Rate for Payer: Cash Price |
$79.92
|
| Rate for Payer: Central Health Plan Commercial |
$142.08
|
| Rate for Payer: Cigna of CA HMO |
$124.32
|
| Rate for Payer: Cigna of CA PPO |
$124.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$831.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$748.16
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$554.19
|
| Rate for Payer: EPIC Health Plan Transplant |
$554.19
|
| Rate for Payer: Galaxy Health WC |
$150.96
|
| Rate for Payer: Global Benefits Group Commercial |
$106.56
|
| Rate for Payer: Health Management Network EPO/PPO |
$159.84
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$133.20
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$908.87
|
| Rate for Payer: IEHP medi-cal |
$914.42
|
| Rate for Payer: IEHP Medicare Advantage |
$554.19
|
| Rate for Payer: Innovage PACE Commercial |
$831.29
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$118.46
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$554.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$35.52
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$742.62
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$742.62
|
| Rate for Payer: Multiplan Commercial |
$133.20
|
| Rate for Payer: Networks By Design Commercial |
$88.80
|
| Rate for Payer: Prime Health Services Commercial |
$150.96
|
| Rate for Payer: Prime Health Services Medicare |
$587.44
|
| Rate for Payer: Riverside University Health MISP |
$609.61
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$106.56
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$106.56
|
| Rate for Payer: United Healthcare All Other Commercial |
$88.80
|
| Rate for Payer: United Healthcare All Other HMO |
$88.80
|
| Rate for Payer: United Healthcare HMO Rider |
$88.80
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$88.80
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$831.29
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$609.61
|
| Rate for Payer: Vantage Medical Group Senior |
$554.19
|
|
|
Ciliary body destruction; cyclophotocoagulation, transscleral
|
Facility
OP
|
$15,354.00
|
|
|
Service Code
|
CPT 66710
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,919.67 |
| Max. Negotiated Rate |
$15,354.00 |
| Rate for Payer: Adventist Health Medi-Cal |
$2,919.67
|
| Rate for Payer: Aetna of CA HMO/PPO |
$6,248.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$4,379.50
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3,211.64
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2,919.67
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$4,736.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,779.00
|
| 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 |
$2,919.67
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4,379.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,941.55
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$2,919.67
|
| Rate for Payer: EPIC Health Plan Transplant |
$2,919.67
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$4,788.26
|
| Rate for Payer: IEHP medi-cal |
$4,817.46
|
| Rate for Payer: IEHP Medicare Advantage |
$2,919.67
|
| Rate for Payer: Innovage PACE Commercial |
$4,379.50
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,919.67
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3,912.36
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3,912.36
|
| Rate for Payer: Prime Health Services Medicare |
$3,094.85
|
| Rate for Payer: Riverside University Health MISP |
$3,211.64
|
| 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 |
$4,379.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3,211.64
|
| Rate for Payer: Vantage Medical Group Senior |
$2,919.67
|
|
