|
POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET [25424]
|
Facility
|
IP
|
$1.76
|
|
|
Service Code
|
NDC 6068743199
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$1.58 |
| Rate for Payer: Adventist Health Commercial |
$0.35
|
| Rate for Payer: Blue Shield of California Commercial |
$1.41
|
| Rate for Payer: Blue Shield of California EPN |
$0.89
|
| Rate for Payer: Cash Price |
$0.79
|
| Rate for Payer: Central Health Plan Commercial |
$1.41
|
| Rate for Payer: Cigna of CA HMO |
$1.23
|
| Rate for Payer: Cigna of CA PPO |
$1.23
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.70
|
| Rate for Payer: EPIC Health Plan Senior |
$0.70
|
| Rate for Payer: Galaxy Health WC |
$1.50
|
| Rate for Payer: Global Benefits Group Commercial |
$1.06
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.58
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.12
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.35
|
| Rate for Payer: Multiplan Commercial |
$1.32
|
| Rate for Payer: Networks By Design Commercial |
$1.14
|
| Rate for Payer: Prime Health Services Commercial |
$1.50
|
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET [25424]
|
Facility
|
OP
|
$1.06
|
|
|
Service Code
|
NDC 9999925424
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$0.95 |
| Rate for Payer: Adventist Health Commercial |
$0.21
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.64
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.90
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.58
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.80
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.51
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.62
|
| Rate for Payer: Blue Shield of California Commercial |
$0.67
|
| Rate for Payer: Blue Shield of California EPN |
$0.42
|
| Rate for Payer: Cash Price |
$0.48
|
| Rate for Payer: Central Health Plan Commercial |
$0.85
|
| Rate for Payer: Cigna of CA HMO |
$0.74
|
| Rate for Payer: Cigna of CA PPO |
$0.74
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.90
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.90
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.90
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.74
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.42
|
| Rate for Payer: EPIC Health Plan Senior |
$0.42
|
| Rate for Payer: Galaxy Health WC |
$0.90
|
| Rate for Payer: Global Benefits Group Commercial |
$0.64
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.95
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.67
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.38
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.21
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.74
|
| Rate for Payer: Multiplan Commercial |
$0.80
|
| Rate for Payer: Networks By Design Commercial |
$0.69
|
| Rate for Payer: Prime Health Services Commercial |
$0.90
|
| Rate for Payer: Riverside University Health System MISP |
$0.42
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.64
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.64
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.53
|
| Rate for Payer: United Healthcare All Other HMO |
$0.53
|
| Rate for Payer: United Healthcare HMO Rider |
$0.53
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.53
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.90
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.90
|
| Rate for Payer: Vantage Medical Group Senior |
$0.90
|
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET [25424]
|
Facility
|
OP
|
$2.02
|
|
|
Service Code
|
NDC 6068743198
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.40 |
| Max. Negotiated Rate |
$1.82 |
| Rate for Payer: Adventist Health Commercial |
$0.40
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.23
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.72
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.11
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.51
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.98
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.18
|
| Rate for Payer: Blue Shield of California Commercial |
$1.28
|
| Rate for Payer: Blue Shield of California EPN |
$0.81
|
| Rate for Payer: Cash Price |
$0.91
|
| Rate for Payer: Central Health Plan Commercial |
$1.62
|
| Rate for Payer: Cigna of CA HMO |
$1.41
|
| Rate for Payer: Cigna of CA PPO |
$1.41
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.72
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.72
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.72
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.81
|
| Rate for Payer: EPIC Health Plan Senior |
$0.81
|
| Rate for Payer: Galaxy Health WC |
$1.72
|
| Rate for Payer: Global Benefits Group Commercial |
$1.21
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.82
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.28
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.73
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.40
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1.41
|
| Rate for Payer: Multiplan Commercial |
$1.51
|
| Rate for Payer: Networks By Design Commercial |
$1.31
|
| Rate for Payer: Prime Health Services Commercial |
$1.72
|
| Rate for Payer: Riverside University Health System MISP |
$0.81
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.21
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.21
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.01
|
| Rate for Payer: United Healthcare All Other HMO |
$1.01
|
| Rate for Payer: United Healthcare HMO Rider |
$1.01
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.72
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.72
|
| Rate for Payer: Vantage Medical Group Senior |
$1.72
|
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET [25424]
|
Facility
|
IP
|
$1.05
|
|
|
Service Code
|
NDC 8770142814
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$0.95 |
| Rate for Payer: Adventist Health Commercial |
$0.21
|
| Rate for Payer: Blue Shield of California Commercial |
$0.84
|
| Rate for Payer: Blue Shield of California EPN |
$0.53
|
| Rate for Payer: Cash Price |
$0.47
|
| Rate for Payer: Central Health Plan Commercial |
$0.84
|
| Rate for Payer: Cigna of CA HMO |
$0.74
|
| Rate for Payer: Cigna of CA PPO |
$0.74
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.74
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.42
|
| Rate for Payer: EPIC Health Plan Senior |
$0.42
|
| Rate for Payer: Galaxy Health WC |
$0.89
|
| Rate for Payer: Global Benefits Group Commercial |
$0.63
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.95
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.67
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.21
|
| Rate for Payer: Multiplan Commercial |
$0.79
|
| Rate for Payer: Networks By Design Commercial |
$0.68
|
| Rate for Payer: Prime Health Services Commercial |
$0.89
|
|
|
POLYETHYLENE GLYCOL 400 1 % EYE DROPS [232731]
|
Facility
|
OP
|
$0.51
|
|
|
Service Code
|
NDC 7430001067
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.46 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.31
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.43
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.28
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.38
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.30
|
| Rate for Payer: Blue Shield of California Commercial |
$0.32
|
| Rate for Payer: Blue Shield of California EPN |
$0.20
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Central Health Plan Commercial |
$0.41
|
| Rate for Payer: Cigna of CA HMO |
$0.36
|
| Rate for Payer: Cigna of CA PPO |
$0.36
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.43
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.43
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.43
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.20
|
| Rate for Payer: EPIC Health Plan Senior |
$0.20
|
| Rate for Payer: Galaxy Health WC |
$0.43
|
| Rate for Payer: Global Benefits Group Commercial |
$0.31
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.46
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.32
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.19
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.36
|
| Rate for Payer: Multiplan Commercial |
$0.38
|
| Rate for Payer: Networks By Design Commercial |
$0.33
|
| Rate for Payer: Prime Health Services Commercial |
$0.43
|
| Rate for Payer: Riverside University Health System MISP |
$0.20
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.31
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.31
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.26
|
| Rate for Payer: United Healthcare All Other HMO |
$0.26
|
| Rate for Payer: United Healthcare HMO Rider |
$0.26
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.26
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.43
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.43
|
| Rate for Payer: Vantage Medical Group Senior |
$0.43
|
|
|
POLYETHYLENE GLYCOL 400 1 % EYE DROPS [232731]
|
Facility
|
IP
|
$0.51
|
|
|
Service Code
|
NDC 7430001067
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.46 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Blue Shield of California Commercial |
$0.41
|
| Rate for Payer: Blue Shield of California EPN |
$0.26
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Central Health Plan Commercial |
$0.41
|
| Rate for Payer: Cigna of CA HMO |
$0.36
|
| Rate for Payer: Cigna of CA PPO |
$0.36
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.20
|
| Rate for Payer: EPIC Health Plan Senior |
$0.20
|
| Rate for Payer: Galaxy Health WC |
$0.43
|
| Rate for Payer: Global Benefits Group Commercial |
$0.31
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.46
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.32
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.38
|
| Rate for Payer: Networks By Design Commercial |
$0.33
|
| Rate for Payer: Prime Health Services Commercial |
$0.43
|
|
|
POLYMYXIN B SULFATE 10,000 UNIT-TRIMETHOPRIM 1 MG/ML EYE DROPS [111465]
|
Facility
|
OP
|
$1.24
|
|
|
Service Code
|
NDC 6131462810
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$1.12 |
| Rate for Payer: Adventist Health Commercial |
$0.25
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.75
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.05
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.68
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.93
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.60
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.72
|
| Rate for Payer: Blue Shield of California Commercial |
$0.79
|
| Rate for Payer: Blue Shield of California EPN |
$0.49
|
| Rate for Payer: Cash Price |
$0.56
|
| Rate for Payer: Central Health Plan Commercial |
$0.99
|
| Rate for Payer: Cigna of CA HMO |
$0.87
|
| Rate for Payer: Cigna of CA PPO |
$0.87
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.05
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.05
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.50
|
| Rate for Payer: EPIC Health Plan Senior |
$0.50
|
| 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 |
$1.12
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.79
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.45
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.87
|
| Rate for Payer: Multiplan Commercial |
$0.93
|
| Rate for Payer: Networks By Design Commercial |
$0.81
|
| Rate for Payer: Prime Health Services Commercial |
$1.05
|
| Rate for Payer: Riverside University Health System MISP |
$0.50
|
| 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 Commercial/Exchange |
$1.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.05
|
| Rate for Payer: Vantage Medical Group Senior |
$1.05
|
|
|
POLYMYXIN B SULFATE 10,000 UNIT-TRIMETHOPRIM 1 MG/ML EYE DROPS [111465]
|
Facility
|
IP
|
$1.24
|
|
|
Service Code
|
NDC 6131462810
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$1.12 |
| Rate for Payer: Adventist Health Commercial |
$0.25
|
| Rate for Payer: Blue Shield of California Commercial |
$0.99
|
| Rate for Payer: Blue Shield of California EPN |
$0.62
|
| Rate for Payer: Cash Price |
$0.56
|
| Rate for Payer: Central Health Plan Commercial |
$0.99
|
| Rate for Payer: Cigna of CA HMO |
$0.87
|
| Rate for Payer: Cigna of CA PPO |
$0.87
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.50
|
| Rate for Payer: EPIC Health Plan Senior |
$0.50
|
| 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 |
$1.12
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.79
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.25
|
| Rate for Payer: Multiplan Commercial |
$0.93
|
| Rate for Payer: Networks By Design Commercial |
$0.81
|
| Rate for Payer: Prime Health Services Commercial |
$1.05
|
|
|
POLYMYXIN B SULFATE 500,000 UNIT SOLUTION FOR INJECTION [6393]
|
Facility
|
OP
|
$12.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.40 |
| Max. Negotiated Rate |
$10.80 |
| Rate for Payer: Adventist Health Commercial |
$2.40
|
| Rate for Payer: Aetna of CA HMO/PPO |
$7.29
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$10.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6.60
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9.00
|
| Rate for Payer: Blue Shield of California Commercial |
$7.61
|
| Rate for Payer: Blue Shield of California EPN |
$4.79
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Central Health Plan Commercial |
$9.60
|
| Rate for Payer: Cigna of CA HMO |
$8.40
|
| Rate for Payer: Cigna of CA PPO |
$8.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$10.20
|
| Rate for Payer: Dignity Health Medicare Advantage |
$10.20
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$8.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.80
|
| Rate for Payer: EPIC Health Plan Senior |
$4.80
|
| Rate for Payer: Galaxy Health WC |
$10.20
|
| Rate for Payer: Global Benefits Group Commercial |
$7.20
|
| Rate for Payer: Health Management Network EPO/PPO |
$10.80
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$7.62
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$7.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.40
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$8.40
|
| Rate for Payer: Multiplan Commercial |
$9.00
|
| Rate for Payer: Networks By Design Commercial |
$6.00
|
| Rate for Payer: Prime Health Services Commercial |
$10.20
|
| Rate for Payer: Riverside University Health System MISP |
$4.80
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$7.20
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$7.20
|
| Rate for Payer: United Healthcare All Other Commercial |
$4.50
|
| Rate for Payer: United Healthcare All Other HMO |
$4.38
|
| Rate for Payer: United Healthcare HMO Rider |
$4.29
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.93
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$10.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$10.20
|
| Rate for Payer: Vantage Medical Group Senior |
$10.20
|
|
|
POLYMYXIN B SULFATE 500,000 UNIT SOLUTION FOR INJECTION [6393]
|
Facility
|
IP
|
$12.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.40 |
| Max. Negotiated Rate |
$10.80 |
| Rate for Payer: Adventist Health Commercial |
$2.40
|
| Rate for Payer: Blue Shield of California Commercial |
$9.62
|
| Rate for Payer: Blue Shield of California EPN |
$6.05
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Central Health Plan Commercial |
$9.60
|
| Rate for Payer: Cigna of CA HMO |
$8.40
|
| Rate for Payer: Cigna of CA PPO |
$8.40
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$8.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.80
|
| Rate for Payer: EPIC Health Plan Senior |
$4.80
|
| Rate for Payer: Galaxy Health WC |
$10.20
|
| Rate for Payer: Global Benefits Group Commercial |
$7.20
|
| Rate for Payer: Health Management Network EPO/PPO |
$10.80
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$7.62
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$7.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.40
|
| Rate for Payer: Multiplan Commercial |
$9.00
|
| Rate for Payer: Networks By Design Commercial |
$6.00
|
| Rate for Payer: Prime Health Services Commercial |
$10.20
|
| Rate for Payer: United Healthcare All Other Commercial |
$4.50
|
| Rate for Payer: United Healthcare All Other HMO |
$4.38
|
| Rate for Payer: United Healthcare HMO Rider |
$4.29
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.93
|
|
|
POLYOXYL (100) STEARYL ETHER (BULK) 100 % WAX [192296]
|
Facility
|
IP
|
$1.73
|
|
|
Service Code
|
NDC 5192723020
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$1.56 |
| Rate for Payer: Adventist Health Commercial |
$0.35
|
| Rate for Payer: Blue Shield of California Commercial |
$1.39
|
| Rate for Payer: Blue Shield of California EPN |
$0.87
|
| Rate for Payer: Cash Price |
$0.78
|
| Rate for Payer: Central Health Plan Commercial |
$1.38
|
| Rate for Payer: Cigna of CA HMO |
$1.21
|
| Rate for Payer: Cigna of CA PPO |
$1.21
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.69
|
| Rate for Payer: EPIC Health Plan Senior |
$0.69
|
| Rate for Payer: Galaxy Health WC |
$1.47
|
| Rate for Payer: Global Benefits Group Commercial |
$1.04
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.56
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.10
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.35
|
| Rate for Payer: Multiplan Commercial |
$1.30
|
| Rate for Payer: Networks By Design Commercial |
$1.12
|
| Rate for Payer: Prime Health Services Commercial |
$1.47
|
|
|
POLYOXYL (100) STEARYL ETHER (BULK) 100 % WAX [192296]
|
Facility
|
OP
|
$1.73
|
|
|
Service Code
|
NDC 5192723020
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$1.56 |
| Rate for Payer: Adventist Health Commercial |
$0.35
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.05
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.47
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.95
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.30
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.84
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.01
|
| Rate for Payer: Blue Shield of California Commercial |
$1.10
|
| Rate for Payer: Blue Shield of California EPN |
$0.69
|
| Rate for Payer: Cash Price |
$0.78
|
| Rate for Payer: Central Health Plan Commercial |
$1.38
|
| Rate for Payer: Cigna of CA HMO |
$1.21
|
| Rate for Payer: Cigna of CA PPO |
$1.21
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.47
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.47
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.47
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.69
|
| Rate for Payer: EPIC Health Plan Senior |
$0.69
|
| Rate for Payer: Galaxy Health WC |
$1.47
|
| Rate for Payer: Global Benefits Group Commercial |
$1.04
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.56
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.10
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.63
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.35
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1.21
|
| Rate for Payer: Multiplan Commercial |
$1.30
|
| Rate for Payer: Networks By Design Commercial |
$1.12
|
| Rate for Payer: Prime Health Services Commercial |
$1.47
|
| Rate for Payer: Riverside University Health System MISP |
$0.69
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.04
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.04
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.87
|
| Rate for Payer: United Healthcare All Other HMO |
$0.87
|
| Rate for Payer: United Healthcare HMO Rider |
$0.87
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.87
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.47
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.47
|
| Rate for Payer: Vantage Medical Group Senior |
$1.47
|
|
|
PORACTANT ALFA 120 MG/1.5 ML INTRATRACHEAL SUSPENSION [27047]
|
Facility
|
OP
|
$502.65
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$100.53 |
| Max. Negotiated Rate |
$452.38 |
| Rate for Payer: Adventist Health Commercial |
$100.53
|
| Rate for Payer: Aetna of CA HMO/PPO |
$305.26
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$427.25
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$276.46
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$376.99
|
| Rate for Payer: Blue Shield of California Commercial |
$318.68
|
| Rate for Payer: Blue Shield of California EPN |
$200.56
|
| Rate for Payer: Cash Price |
$226.19
|
| Rate for Payer: Central Health Plan Commercial |
$402.12
|
| Rate for Payer: Cigna of CA HMO |
$351.86
|
| Rate for Payer: Cigna of CA PPO |
$351.86
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$427.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$427.25
|
| Rate for Payer: Dignity Health Medicare Advantage |
$427.25
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$351.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$201.06
|
| Rate for Payer: EPIC Health Plan Senior |
$201.06
|
| Rate for Payer: Galaxy Health WC |
$427.25
|
| Rate for Payer: Global Benefits Group Commercial |
$301.59
|
| Rate for Payer: Health Management Network EPO/PPO |
$452.38
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$319.18
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$296.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$100.53
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$351.86
|
| Rate for Payer: Multiplan Commercial |
$376.99
|
| Rate for Payer: Networks By Design Commercial |
$251.32
|
| Rate for Payer: Prime Health Services Commercial |
$427.25
|
| Rate for Payer: Riverside University Health System MISP |
$201.06
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$301.59
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$301.59
|
| Rate for Payer: United Healthcare All Other Commercial |
$188.64
|
| Rate for Payer: United Healthcare All Other HMO |
$183.62
|
| Rate for Payer: United Healthcare HMO Rider |
$179.65
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$164.62
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$427.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$427.25
|
| Rate for Payer: Vantage Medical Group Senior |
$427.25
|
|
|
PORACTANT ALFA 120 MG/1.5 ML INTRATRACHEAL SUSPENSION [27047]
|
Facility
|
IP
|
$502.65
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$100.53 |
| Max. Negotiated Rate |
$452.38 |
| Rate for Payer: Adventist Health Commercial |
$100.53
|
| Rate for Payer: Blue Shield of California Commercial |
$403.13
|
| Rate for Payer: Blue Shield of California EPN |
$253.34
|
| Rate for Payer: Cash Price |
$226.19
|
| Rate for Payer: Central Health Plan Commercial |
$402.12
|
| Rate for Payer: Cigna of CA HMO |
$351.86
|
| Rate for Payer: Cigna of CA PPO |
$351.86
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$351.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$201.06
|
| Rate for Payer: EPIC Health Plan Senior |
$201.06
|
| Rate for Payer: Galaxy Health WC |
$427.25
|
| Rate for Payer: Global Benefits Group Commercial |
$301.59
|
| Rate for Payer: Health Management Network EPO/PPO |
$452.38
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$319.18
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$296.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$100.53
|
| Rate for Payer: Multiplan Commercial |
$376.99
|
| Rate for Payer: Networks By Design Commercial |
$251.32
|
| Rate for Payer: Prime Health Services Commercial |
$427.25
|
| Rate for Payer: United Healthcare All Other Commercial |
$188.64
|
| Rate for Payer: United Healthcare All Other HMO |
$183.62
|
| Rate for Payer: United Healthcare HMO Rider |
$179.65
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$164.62
|
|
|
PORACTANT ALFA 240 MG/3 ML INTRATRACHEAL SUSPENSION [117872]
|
Facility
|
OP
|
$495.58
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$99.12 |
| Max. Negotiated Rate |
$446.02 |
| Rate for Payer: Adventist Health Commercial |
$99.12
|
| Rate for Payer: Aetna of CA HMO/PPO |
$300.97
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$421.24
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$272.57
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$371.69
|
| Rate for Payer: Blue Shield of California Commercial |
$314.20
|
| Rate for Payer: Blue Shield of California EPN |
$197.74
|
| Rate for Payer: Cash Price |
$223.01
|
| Rate for Payer: Central Health Plan Commercial |
$396.46
|
| Rate for Payer: Cigna of CA HMO |
$346.91
|
| Rate for Payer: Cigna of CA PPO |
$346.91
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$421.24
|
| Rate for Payer: Dignity Health Medi-Cal |
$421.24
|
| Rate for Payer: Dignity Health Medicare Advantage |
$421.24
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$346.91
|
| Rate for Payer: EPIC Health Plan Commercial |
$198.23
|
| Rate for Payer: EPIC Health Plan Senior |
$198.23
|
| Rate for Payer: Galaxy Health WC |
$421.24
|
| Rate for Payer: Global Benefits Group Commercial |
$297.35
|
| Rate for Payer: Health Management Network EPO/PPO |
$446.02
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$314.69
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$292.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$99.12
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$346.91
|
| Rate for Payer: Multiplan Commercial |
$371.69
|
| Rate for Payer: Networks By Design Commercial |
$247.79
|
| Rate for Payer: Prime Health Services Commercial |
$421.24
|
| Rate for Payer: Riverside University Health System MISP |
$198.23
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$297.35
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$297.35
|
| Rate for Payer: United Healthcare All Other Commercial |
$185.99
|
| Rate for Payer: United Healthcare All Other HMO |
$181.04
|
| Rate for Payer: United Healthcare HMO Rider |
$177.12
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$162.30
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$421.24
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$421.24
|
| Rate for Payer: Vantage Medical Group Senior |
$421.24
|
|
|
PORACTANT ALFA 240 MG/3 ML INTRATRACHEAL SUSPENSION [117872]
|
Facility
|
IP
|
$495.58
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$99.12 |
| Max. Negotiated Rate |
$446.02 |
| Rate for Payer: Adventist Health Commercial |
$99.12
|
| Rate for Payer: Blue Shield of California Commercial |
$397.46
|
| Rate for Payer: Blue Shield of California EPN |
$249.77
|
| Rate for Payer: Cash Price |
$223.01
|
| Rate for Payer: Central Health Plan Commercial |
$396.46
|
| Rate for Payer: Cigna of CA HMO |
$346.91
|
| Rate for Payer: Cigna of CA PPO |
$346.91
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$346.91
|
| Rate for Payer: EPIC Health Plan Commercial |
$198.23
|
| Rate for Payer: EPIC Health Plan Senior |
$198.23
|
| Rate for Payer: Galaxy Health WC |
$421.24
|
| Rate for Payer: Global Benefits Group Commercial |
$297.35
|
| Rate for Payer: Health Management Network EPO/PPO |
$446.02
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$314.69
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$292.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$99.12
|
| Rate for Payer: Multiplan Commercial |
$371.69
|
| Rate for Payer: Networks By Design Commercial |
$247.79
|
| Rate for Payer: Prime Health Services Commercial |
$421.24
|
| Rate for Payer: United Healthcare All Other Commercial |
$185.99
|
| Rate for Payer: United Healthcare All Other HMO |
$181.04
|
| Rate for Payer: United Healthcare HMO Rider |
$177.12
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$162.30
|
|
|
PORFIMER 75 MG INTRAVENOUS SOLUTION [14472]
|
Facility
|
IP
|
$27,987.60
|
|
|
Service Code
|
HCPCS J9600
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5,597.52 |
| Max. Negotiated Rate |
$25,188.84 |
| Rate for Payer: Adventist Health Commercial |
$5,597.52
|
| Rate for Payer: Blue Shield of California Commercial |
$22,446.06
|
| Rate for Payer: Blue Shield of California EPN |
$14,105.75
|
| Rate for Payer: Cash Price |
$12,594.42
|
| Rate for Payer: Central Health Plan Commercial |
$22,390.08
|
| Rate for Payer: Cigna of CA HMO |
$19,591.32
|
| Rate for Payer: Cigna of CA PPO |
$19,591.32
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$19,591.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$11,195.04
|
| Rate for Payer: EPIC Health Plan Senior |
$11,195.04
|
| Rate for Payer: Galaxy Health WC |
$23,789.46
|
| Rate for Payer: Global Benefits Group Commercial |
$16,792.56
|
| Rate for Payer: Health Management Network EPO/PPO |
$25,188.84
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$17,772.13
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$16,512.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5,597.52
|
| Rate for Payer: Multiplan Commercial |
$20,990.70
|
| Rate for Payer: Networks By Design Commercial |
$13,993.80
|
| Rate for Payer: Prime Health Services Commercial |
$23,789.46
|
| Rate for Payer: United Healthcare All Other Commercial |
$10,503.75
|
| Rate for Payer: United Healthcare All Other HMO |
$10,223.87
|
| Rate for Payer: United Healthcare HMO Rider |
$10,002.77
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$9,165.94
|
|
|
PORFIMER 75 MG INTRAVENOUS SOLUTION [14472]
|
Facility
|
OP
|
$27,987.60
|
|
|
Service Code
|
HCPCS J9600
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5,190.78 |
| Max. Negotiated Rate |
$142,530.53 |
| Rate for Payer: Adventist Health Commercial |
$5,597.52
|
| Rate for Payer: Aetna of CA HMO/PPO |
$142,530.53
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$23,789.46
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$15,393.18
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$20,990.70
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$5,190.78
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6,477.64
|
| Rate for Payer: Blue Shield of California Commercial |
$30,786.36
|
| Rate for Payer: Blue Shield of California EPN |
$27,987.60
|
| Rate for Payer: Cash Price |
$12,594.42
|
| Rate for Payer: Cash Price |
$12,594.42
|
| Rate for Payer: Central Health Plan Commercial |
$22,390.08
|
| Rate for Payer: Cigna of CA HMO |
$19,591.32
|
| Rate for Payer: Cigna of CA PPO |
$19,591.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$23,789.46
|
| Rate for Payer: Dignity Health Medi-Cal |
$23,789.46
|
| Rate for Payer: Dignity Health Medicare Advantage |
$23,789.46
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$19,591.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$11,195.04
|
| Rate for Payer: EPIC Health Plan Senior |
$11,195.04
|
| Rate for Payer: Galaxy Health WC |
$23,789.46
|
| Rate for Payer: Global Benefits Group Commercial |
$16,792.56
|
| Rate for Payer: Health Management Network EPO/PPO |
$25,188.84
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$17,772.13
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$10,159.50
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$16,512.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5,597.52
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$19,591.32
|
| Rate for Payer: Multiplan Commercial |
$20,990.70
|
| Rate for Payer: Networks By Design Commercial |
$13,993.80
|
| Rate for Payer: Prime Health Services Commercial |
$23,789.46
|
| Rate for Payer: Riverside University Health System MISP |
$11,195.04
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$16,792.56
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$16,792.56
|
| Rate for Payer: United Healthcare All Other Commercial |
$10,503.75
|
| Rate for Payer: United Healthcare All Other HMO |
$10,223.87
|
| Rate for Payer: United Healthcare HMO Rider |
$10,002.77
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$9,165.94
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$23,789.46
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$23,789.46
|
| Rate for Payer: Vantage Medical Group Senior |
$23,789.46
|
|
|
POSACONAZOLE 100 MG TABLET,DELAYED RELEASE [204306]
|
Facility
|
OP
|
$59.25
|
|
|
Service Code
|
NDC 0904714904
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$11.85 |
| Max. Negotiated Rate |
$53.33 |
| Rate for Payer: Adventist Health Commercial |
$11.85
|
| Rate for Payer: Aetna of CA HMO/PPO |
$35.98
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$50.36
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$32.59
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$44.44
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$28.69
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34.47
|
| Rate for Payer: Blue Shield of California Commercial |
$37.56
|
| Rate for Payer: Blue Shield of California EPN |
$23.64
|
| Rate for Payer: Cash Price |
$26.66
|
| Rate for Payer: Central Health Plan Commercial |
$47.40
|
| Rate for Payer: Cigna of CA HMO |
$41.48
|
| Rate for Payer: Cigna of CA PPO |
$41.48
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$50.36
|
| Rate for Payer: Dignity Health Medi-Cal |
$50.36
|
| Rate for Payer: Dignity Health Medicare Advantage |
$50.36
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$41.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$23.70
|
| Rate for Payer: EPIC Health Plan Senior |
$23.70
|
| Rate for Payer: Galaxy Health WC |
$50.36
|
| Rate for Payer: Global Benefits Group Commercial |
$35.55
|
| Rate for Payer: Health Management Network EPO/PPO |
$53.33
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$37.62
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$21.51
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$34.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.85
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$41.48
|
| Rate for Payer: Multiplan Commercial |
$44.44
|
| Rate for Payer: Networks By Design Commercial |
$38.51
|
| Rate for Payer: Prime Health Services Commercial |
$50.36
|
| Rate for Payer: Riverside University Health System MISP |
$23.70
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$35.55
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$35.55
|
| Rate for Payer: United Healthcare All Other Commercial |
$29.62
|
| Rate for Payer: United Healthcare All Other HMO |
$29.62
|
| Rate for Payer: United Healthcare HMO Rider |
$29.62
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$29.62
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$50.36
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$50.36
|
| Rate for Payer: Vantage Medical Group Senior |
$50.36
|
|
|
POSACONAZOLE 100 MG TABLET,DELAYED RELEASE [204306]
|
Facility
|
IP
|
$5.00
|
|
|
Service Code
|
NDC 0527213335
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$4.50 |
| Rate for Payer: Adventist Health Commercial |
$1.00
|
| Rate for Payer: Blue Shield of California Commercial |
$4.01
|
| Rate for Payer: Blue Shield of California EPN |
$2.52
|
| Rate for Payer: Cash Price |
$2.25
|
| Rate for Payer: Central Health Plan Commercial |
$4.00
|
| Rate for Payer: Cigna of CA HMO |
$3.50
|
| Rate for Payer: Cigna of CA PPO |
$3.50
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$3.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.00
|
| Rate for Payer: EPIC Health Plan Senior |
$2.00
|
| Rate for Payer: Galaxy Health WC |
$4.25
|
| Rate for Payer: Global Benefits Group Commercial |
$3.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$4.50
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$3.17
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.00
|
| Rate for Payer: Multiplan Commercial |
$3.75
|
| Rate for Payer: Networks By Design Commercial |
$3.25
|
| Rate for Payer: Prime Health Services Commercial |
$4.25
|
|
|
POSACONAZOLE 100 MG TABLET,DELAYED RELEASE [204306]
|
Facility
|
OP
|
$5.00
|
|
|
Service Code
|
NDC 0527213335
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$4.50 |
| Rate for Payer: Adventist Health Commercial |
$1.00
|
| Rate for Payer: Aetna of CA HMO/PPO |
$3.04
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.25
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.75
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.75
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$2.42
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.91
|
| Rate for Payer: Blue Shield of California Commercial |
$3.17
|
| Rate for Payer: Blue Shield of California EPN |
$2.00
|
| Rate for Payer: Cash Price |
$2.25
|
| Rate for Payer: Central Health Plan Commercial |
$4.00
|
| Rate for Payer: Cigna of CA HMO |
$3.50
|
| Rate for Payer: Cigna of CA PPO |
$3.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.25
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4.25
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$3.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.00
|
| Rate for Payer: EPIC Health Plan Senior |
$2.00
|
| Rate for Payer: Galaxy Health WC |
$4.25
|
| Rate for Payer: Global Benefits Group Commercial |
$3.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$4.50
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$3.17
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.81
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$3.50
|
| Rate for Payer: Multiplan Commercial |
$3.75
|
| Rate for Payer: Networks By Design Commercial |
$3.25
|
| Rate for Payer: Prime Health Services Commercial |
$4.25
|
| Rate for Payer: Riverside University Health System MISP |
$2.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.50
|
| Rate for Payer: United Healthcare All Other HMO |
$2.50
|
| Rate for Payer: United Healthcare HMO Rider |
$2.50
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.25
|
| Rate for Payer: Vantage Medical Group Senior |
$4.25
|
|
|
POSACONAZOLE 100 MG TABLET,DELAYED RELEASE [204306]
|
Facility
|
IP
|
$59.25
|
|
|
Service Code
|
NDC 0904714904
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$11.85 |
| Max. Negotiated Rate |
$53.33 |
| Rate for Payer: Adventist Health Commercial |
$11.85
|
| Rate for Payer: Blue Shield of California Commercial |
$47.52
|
| Rate for Payer: Blue Shield of California EPN |
$29.86
|
| Rate for Payer: Cash Price |
$26.66
|
| Rate for Payer: Central Health Plan Commercial |
$47.40
|
| Rate for Payer: Cigna of CA HMO |
$41.48
|
| Rate for Payer: Cigna of CA PPO |
$41.48
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$41.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$23.70
|
| Rate for Payer: EPIC Health Plan Senior |
$23.70
|
| Rate for Payer: Galaxy Health WC |
$50.36
|
| Rate for Payer: Global Benefits Group Commercial |
$35.55
|
| Rate for Payer: Health Management Network EPO/PPO |
$53.33
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$37.62
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$34.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.85
|
| Rate for Payer: Multiplan Commercial |
$44.44
|
| Rate for Payer: Networks By Design Commercial |
$38.51
|
| Rate for Payer: Prime Health Services Commercial |
$50.36
|
|
|
POSACONAZOLE 100 MG TABLET,DELAYED RELEASE [204306]
|
Facility
|
IP
|
$9.00
|
|
|
Service Code
|
NDC 7074825807
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.80 |
| Max. Negotiated Rate |
$8.10 |
| Rate for Payer: Adventist Health Commercial |
$1.80
|
| Rate for Payer: Blue Shield of California Commercial |
$7.22
|
| Rate for Payer: Blue Shield of California EPN |
$4.54
|
| Rate for Payer: Cash Price |
$4.05
|
| Rate for Payer: Central Health Plan Commercial |
$7.20
|
| Rate for Payer: Cigna of CA HMO |
$6.30
|
| Rate for Payer: Cigna of CA PPO |
$6.30
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$6.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.60
|
| Rate for Payer: EPIC Health Plan Senior |
$3.60
|
| Rate for Payer: Galaxy Health WC |
$7.65
|
| Rate for Payer: Global Benefits Group Commercial |
$5.40
|
| Rate for Payer: Health Management Network EPO/PPO |
$8.10
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$5.71
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$5.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.80
|
| Rate for Payer: Multiplan Commercial |
$6.75
|
| Rate for Payer: Networks By Design Commercial |
$5.85
|
| Rate for Payer: Prime Health Services Commercial |
$7.65
|
|
|
POSACONAZOLE 100 MG TABLET,DELAYED RELEASE [204306]
|
Facility
|
IP
|
$9.00
|
|
|
Service Code
|
NDC 7231902302
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.80 |
| Max. Negotiated Rate |
$8.10 |
| Rate for Payer: Adventist Health Commercial |
$1.80
|
| Rate for Payer: Blue Shield of California Commercial |
$7.22
|
| Rate for Payer: Blue Shield of California EPN |
$4.54
|
| Rate for Payer: Cash Price |
$4.05
|
| Rate for Payer: Central Health Plan Commercial |
$7.20
|
| Rate for Payer: Cigna of CA HMO |
$6.30
|
| Rate for Payer: Cigna of CA PPO |
$6.30
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$6.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.60
|
| Rate for Payer: EPIC Health Plan Senior |
$3.60
|
| Rate for Payer: Galaxy Health WC |
$7.65
|
| Rate for Payer: Global Benefits Group Commercial |
$5.40
|
| Rate for Payer: Health Management Network EPO/PPO |
$8.10
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$5.71
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$5.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.80
|
| Rate for Payer: Multiplan Commercial |
$6.75
|
| Rate for Payer: Networks By Design Commercial |
$5.85
|
| Rate for Payer: Prime Health Services Commercial |
$7.65
|
|
|
POSACONAZOLE 100 MG TABLET,DELAYED RELEASE [204306]
|
Facility
|
OP
|
$9.00
|
|
|
Service Code
|
NDC 7074825807
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.80 |
| Max. Negotiated Rate |
$8.10 |
| Rate for Payer: Adventist Health Commercial |
$1.80
|
| Rate for Payer: Aetna of CA HMO/PPO |
$5.47
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$7.65
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.95
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$6.75
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$4.36
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5.24
|
| Rate for Payer: Blue Shield of California Commercial |
$5.71
|
| Rate for Payer: Blue Shield of California EPN |
$3.59
|
| Rate for Payer: Cash Price |
$4.05
|
| Rate for Payer: Central Health Plan Commercial |
$7.20
|
| Rate for Payer: Cigna of CA HMO |
$6.30
|
| Rate for Payer: Cigna of CA PPO |
$6.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.65
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.65
|
| Rate for Payer: Dignity Health Medicare Advantage |
$7.65
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$6.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.60
|
| Rate for Payer: EPIC Health Plan Senior |
$3.60
|
| Rate for Payer: Galaxy Health WC |
$7.65
|
| Rate for Payer: Global Benefits Group Commercial |
$5.40
|
| Rate for Payer: Health Management Network EPO/PPO |
$8.10
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$5.71
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$3.27
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$5.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.80
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$6.30
|
| Rate for Payer: Multiplan Commercial |
$6.75
|
| Rate for Payer: Networks By Design Commercial |
$5.85
|
| Rate for Payer: Prime Health Services Commercial |
$7.65
|
| Rate for Payer: Riverside University Health System MISP |
$3.60
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$5.40
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$5.40
|
| Rate for Payer: United Healthcare All Other Commercial |
$4.50
|
| Rate for Payer: United Healthcare All Other HMO |
$4.50
|
| Rate for Payer: United Healthcare HMO Rider |
$4.50
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7.65
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.65
|
| Rate for Payer: Vantage Medical Group Senior |
$7.65
|
|
