|
OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION [91279]
|
Facility
IP
|
$7.80
|
|
|
Service Code
|
CPT J2354
|
| Hospital Charge Code |
1720587
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.56 |
| Max. Negotiated Rate |
$7.02 |
| Rate for Payer: Blue Shield of California Commercial |
$5.85
|
| Rate for Payer: Blue Shield of California EPN |
$4.17
|
| Rate for Payer: Cash Price |
$3.51
|
| Rate for Payer: Central Health Plan Commercial |
$6.24
|
| Rate for Payer: Cigna of CA HMO |
$5.46
|
| Rate for Payer: Cigna of CA PPO |
$5.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.12
|
| Rate for Payer: EPIC Health Plan Transplant |
$3.12
|
| Rate for Payer: Galaxy Health WC |
$6.63
|
| Rate for Payer: Global Benefits Group Commercial |
$4.68
|
| Rate for Payer: Health Management Network EPO/PPO |
$7.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.56
|
| Rate for Payer: Multiplan Commercial |
$5.85
|
| Rate for Payer: Networks By Design Commercial |
$3.90
|
| Rate for Payer: Prime Health Services Commercial |
$6.63
|
|
|
OCTREOTIDE ACETATE 500 MCG/ML INJECTION SOLUTION [91281]
|
Facility
IP
|
$42.00
|
|
|
Service Code
|
CPT J2354
|
| Hospital Charge Code |
1720585
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.40 |
| Max. Negotiated Rate |
$37.80 |
| Rate for Payer: Blue Shield of California Commercial |
$31.50
|
| Rate for Payer: Blue Shield of California Commercial |
$9.68
|
| Rate for Payer: Blue Shield of California Commercial |
$44.72
|
| Rate for Payer: Blue Shield of California EPN |
$31.84
|
| Rate for Payer: Blue Shield of California EPN |
$6.89
|
| Rate for Payer: Blue Shield of California EPN |
$22.43
|
| Rate for Payer: Cash Price |
$5.81
|
| Rate for Payer: Cash Price |
$26.83
|
| Rate for Payer: Cash Price |
$18.90
|
| Rate for Payer: Central Health Plan Commercial |
$10.32
|
| Rate for Payer: Central Health Plan Commercial |
$47.70
|
| Rate for Payer: Central Health Plan Commercial |
$33.60
|
| Rate for Payer: Cigna of CA HMO |
$9.03
|
| Rate for Payer: Cigna of CA HMO |
$29.40
|
| Rate for Payer: Cigna of CA HMO |
$41.74
|
| Rate for Payer: Cigna of CA PPO |
$9.03
|
| Rate for Payer: Cigna of CA PPO |
$41.74
|
| Rate for Payer: Cigna of CA PPO |
$29.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$23.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$16.80
|
| Rate for Payer: EPIC Health Plan Transplant |
$5.16
|
| Rate for Payer: EPIC Health Plan Transplant |
$23.85
|
| Rate for Payer: EPIC Health Plan Transplant |
$16.80
|
| Rate for Payer: Galaxy Health WC |
$35.70
|
| Rate for Payer: Galaxy Health WC |
$10.96
|
| Rate for Payer: Galaxy Health WC |
$50.69
|
| Rate for Payer: Global Benefits Group Commercial |
$35.78
|
| Rate for Payer: Global Benefits Group Commercial |
$7.74
|
| Rate for Payer: Global Benefits Group Commercial |
$25.20
|
| Rate for Payer: Health Management Network EPO/PPO |
$11.61
|
| Rate for Payer: Health Management Network EPO/PPO |
$37.80
|
| Rate for Payer: Health Management Network EPO/PPO |
$53.67
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$39.77
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$8.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$28.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.93
|
| Rate for Payer: Multiplan Commercial |
$44.72
|
| Rate for Payer: Multiplan Commercial |
$9.68
|
| Rate for Payer: Multiplan Commercial |
$31.50
|
| Rate for Payer: Networks By Design Commercial |
$21.00
|
| Rate for Payer: Networks By Design Commercial |
$6.45
|
| Rate for Payer: Networks By Design Commercial |
$29.82
|
| Rate for Payer: Prime Health Services Commercial |
$50.69
|
| Rate for Payer: Prime Health Services Commercial |
$35.70
|
| Rate for Payer: Prime Health Services Commercial |
$10.96
|
|
|
OCTREOTIDE ACETATE 500 MCG/ML INJECTION SOLUTION [91281]
|
Facility
OP
|
$59.63
|
|
|
Service Code
|
CPT J2354
|
| Hospital Charge Code |
1720585
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.90 |
| Max. Negotiated Rate |
$53.67 |
| Rate for Payer: Aetna of CA HMO/PPO |
$7.36
|
| Rate for Payer: Aetna of CA HMO/PPO |
$7.36
|
| Rate for Payer: Aetna of CA HMO/PPO |
$7.36
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$35.70
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$10.96
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$50.69
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$32.80
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$23.10
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$7.10
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$7.10
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$32.80
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$23.10
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$8.85
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$8.85
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$8.85
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9.69
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9.69
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9.69
|
| Rate for Payer: BCBS Transplant Transplant |
$35.78
|
| Rate for Payer: BCBS Transplant Transplant |
$7.74
|
| Rate for Payer: BCBS Transplant Transplant |
$25.20
|
| Rate for Payer: Blue Shield of California Commercial |
$2.45
|
| Rate for Payer: Blue Shield of California Commercial |
$2.45
|
| Rate for Payer: Blue Shield of California Commercial |
$2.45
|
| Rate for Payer: Blue Shield of California EPN |
$2.23
|
| Rate for Payer: Blue Shield of California EPN |
$2.23
|
| Rate for Payer: Blue Shield of California EPN |
$2.23
|
| Rate for Payer: Cash Price |
$26.83
|
| Rate for Payer: Cash Price |
$26.83
|
| Rate for Payer: Cash Price |
$5.81
|
| Rate for Payer: Cash Price |
$18.90
|
| Rate for Payer: Cash Price |
$5.81
|
| Rate for Payer: Cash Price |
$18.90
|
| Rate for Payer: Central Health Plan Commercial |
$10.32
|
| Rate for Payer: Central Health Plan Commercial |
$33.60
|
| Rate for Payer: Central Health Plan Commercial |
$47.70
|
| Rate for Payer: Cigna of CA HMO |
$9.03
|
| Rate for Payer: Cigna of CA HMO |
$29.40
|
| Rate for Payer: Cigna of CA HMO |
$41.74
|
| Rate for Payer: Cigna of CA PPO |
$9.03
|
| Rate for Payer: Cigna of CA PPO |
$41.74
|
| Rate for Payer: Cigna of CA PPO |
$29.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$50.69
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10.96
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$35.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$16.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$23.85
|
| Rate for Payer: EPIC Health Plan Transplant |
$23.85
|
| Rate for Payer: EPIC Health Plan Transplant |
$5.16
|
| Rate for Payer: EPIC Health Plan Transplant |
$16.80
|
| Rate for Payer: Galaxy Health WC |
$35.70
|
| Rate for Payer: Galaxy Health WC |
$10.96
|
| Rate for Payer: Galaxy Health WC |
$50.69
|
| Rate for Payer: Global Benefits Group Commercial |
$7.74
|
| Rate for Payer: Global Benefits Group Commercial |
$35.78
|
| Rate for Payer: Global Benefits Group Commercial |
$25.20
|
| Rate for Payer: Health Management Network EPO/PPO |
$37.80
|
| Rate for Payer: Health Management Network EPO/PPO |
$53.67
|
| Rate for Payer: Health Management Network EPO/PPO |
$11.61
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$31.50
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$9.68
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$44.72
|
| Rate for Payer: IEHP medi-cal |
$0.90
|
| Rate for Payer: IEHP medi-cal |
$0.90
|
| Rate for Payer: IEHP medi-cal |
$0.90
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$28.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$39.77
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$8.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.93
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.40
|
| Rate for Payer: Multiplan Commercial |
$31.50
|
| Rate for Payer: Multiplan Commercial |
$9.68
|
| Rate for Payer: Multiplan Commercial |
$44.72
|
| Rate for Payer: Networks By Design Commercial |
$6.45
|
| Rate for Payer: Networks By Design Commercial |
$21.00
|
| Rate for Payer: Networks By Design Commercial |
$29.82
|
| Rate for Payer: Prime Health Services Commercial |
$10.96
|
| Rate for Payer: Prime Health Services Commercial |
$35.70
|
| Rate for Payer: Prime Health Services Commercial |
$50.69
|
| Rate for Payer: Riverside University Health MISP |
$23.85
|
| Rate for Payer: Riverside University Health MISP |
$16.80
|
| Rate for Payer: Riverside University Health MISP |
$5.16
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$25.20
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$7.74
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$35.78
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$25.20
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$35.78
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$7.74
|
| Rate for Payer: United Healthcare All Other Commercial |
$6.45
|
| Rate for Payer: United Healthcare All Other Commercial |
$29.82
|
| Rate for Payer: United Healthcare All Other Commercial |
$21.00
|
| Rate for Payer: United Healthcare All Other HMO |
$21.00
|
| Rate for Payer: United Healthcare All Other HMO |
$6.45
|
| Rate for Payer: United Healthcare All Other HMO |
$29.82
|
| Rate for Payer: United Healthcare HMO Rider |
$29.82
|
| Rate for Payer: United Healthcare HMO Rider |
$6.45
|
| Rate for Payer: United Healthcare HMO Rider |
$21.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$29.82
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$21.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6.45
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$10.96
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$35.70
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$50.69
|
| Rate for Payer: Vantage Medical Group Senior |
$50.69
|
| Rate for Payer: Vantage Medical Group Senior |
$10.96
|
| Rate for Payer: Vantage Medical Group Senior |
$35.70
|
|
|
OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION [91278]
|
Facility
OP
|
$5.40
|
|
|
Service Code
|
CPT J2354
|
| Hospital Charge Code |
1720586
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.90 |
| Max. Negotiated Rate |
$9.69 |
| Rate for Payer: Aetna of CA HMO/PPO |
$7.36
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$4.59
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.97
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.97
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$8.85
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9.69
|
| Rate for Payer: BCBS Transplant Transplant |
$3.24
|
| Rate for Payer: Blue Shield of California Commercial |
$2.45
|
| Rate for Payer: Blue Shield of California EPN |
$2.23
|
| Rate for Payer: Cash Price |
$2.43
|
| Rate for Payer: Cash Price |
$2.43
|
| Rate for Payer: Central Health Plan Commercial |
$4.32
|
| Rate for Payer: Cigna of CA HMO |
$3.78
|
| Rate for Payer: Cigna of CA PPO |
$3.78
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.16
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.16
|
| Rate for Payer: Galaxy Health WC |
$4.59
|
| Rate for Payer: Global Benefits Group Commercial |
$3.24
|
| Rate for Payer: Health Management Network EPO/PPO |
$4.86
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$4.05
|
| Rate for Payer: IEHP medi-cal |
$0.90
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.08
|
| Rate for Payer: Multiplan Commercial |
$4.05
|
| Rate for Payer: Networks By Design Commercial |
$2.70
|
| Rate for Payer: Prime Health Services Commercial |
$4.59
|
| Rate for Payer: Riverside University Health MISP |
$2.16
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.24
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.24
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.70
|
| Rate for Payer: United Healthcare All Other HMO |
$2.70
|
| Rate for Payer: United Healthcare HMO Rider |
$2.70
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.70
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.59
|
| Rate for Payer: Vantage Medical Group Senior |
$4.59
|
|
|
OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION [91278]
|
Facility
IP
|
$5.40
|
|
|
Service Code
|
CPT J2354
|
| Hospital Charge Code |
1720586
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.08 |
| Max. Negotiated Rate |
$4.86 |
| Rate for Payer: Blue Shield of California Commercial |
$4.05
|
| Rate for Payer: Blue Shield of California EPN |
$2.88
|
| Rate for Payer: Cash Price |
$2.43
|
| Rate for Payer: Central Health Plan Commercial |
$4.32
|
| Rate for Payer: Cigna of CA HMO |
$3.78
|
| Rate for Payer: Cigna of CA PPO |
$3.78
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.16
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.16
|
| Rate for Payer: Galaxy Health WC |
$4.59
|
| Rate for Payer: Global Benefits Group Commercial |
$3.24
|
| Rate for Payer: Health Management Network EPO/PPO |
$4.86
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.08
|
| Rate for Payer: Multiplan Commercial |
$4.05
|
| Rate for Payer: Networks By Design Commercial |
$2.70
|
| Rate for Payer: Prime Health Services Commercial |
$4.59
|
|
|
OCTREOTIDE,MICROSPHERES 20 MG INTRAMUSCULAR WRAP, LONG-ACTING RELEASE [40824435]
|
Facility
IP
|
$5,324.45
|
|
|
Service Code
|
CPT J2353
|
| Hospital Charge Code |
ERX24435
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,064.89 |
| Max. Negotiated Rate |
$4,792.00 |
| Rate for Payer: Blue Shield of California Commercial |
$3,993.34
|
| Rate for Payer: Blue Shield of California EPN |
$2,843.26
|
| Rate for Payer: Cash Price |
$2,396.00
|
| Rate for Payer: Central Health Plan Commercial |
$4,259.56
|
| Rate for Payer: Cigna of CA HMO |
$3,727.12
|
| Rate for Payer: Cigna of CA PPO |
$3,727.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,129.78
|
| Rate for Payer: EPIC Health Plan Transplant |
$2,129.78
|
| Rate for Payer: Galaxy Health WC |
$4,525.78
|
| Rate for Payer: Global Benefits Group Commercial |
$3,194.67
|
| Rate for Payer: Health Management Network EPO/PPO |
$4,792.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3,551.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,064.89
|
| Rate for Payer: Multiplan Commercial |
$3,993.34
|
| Rate for Payer: Networks By Design Commercial |
$2,662.22
|
| Rate for Payer: Prime Health Services Commercial |
$4,525.78
|
|
|
OCTREOTIDE,MICROSPHERES 20 MG INTRAMUSCULAR WRAP, LONG-ACTING RELEASE [40824435]
|
Facility
OP
|
$5,324.45
|
|
|
Service Code
|
CPT J2353
|
| Hospital Charge Code |
ERX24435
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$160.99 |
| Max. Negotiated Rate |
$4,792.00 |
| Rate for Payer: Adventist Health Medi-Cal |
$210.83
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1,306.54
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$263.54
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$231.91
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$231.91
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$160.99
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$176.26
|
| Rate for Payer: BCBS Transplant Transplant |
$3,194.67
|
| Rate for Payer: Blue Shield of California Commercial |
$281.47
|
| Rate for Payer: Blue Shield of California EPN |
$255.88
|
| Rate for Payer: Caremore Medicare Advantage |
$210.83
|
| Rate for Payer: Cash Price |
$2,396.00
|
| Rate for Payer: Cash Price |
$2,396.00
|
| Rate for Payer: Central Health Plan Commercial |
$4,259.56
|
| Rate for Payer: Cigna of CA HMO |
$3,727.12
|
| Rate for Payer: Cigna of CA PPO |
$3,727.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$316.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$284.62
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$210.83
|
| Rate for Payer: EPIC Health Plan Transplant |
$210.83
|
| Rate for Payer: Galaxy Health WC |
$4,525.78
|
| Rate for Payer: Global Benefits Group Commercial |
$3,194.67
|
| Rate for Payer: Health Management Network EPO/PPO |
$4,792.00
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$3,993.34
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$345.76
|
| Rate for Payer: IEHP medi-cal |
$347.87
|
| Rate for Payer: IEHP Medicare Advantage |
$210.83
|
| Rate for Payer: Innovage PACE Commercial |
$316.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3,551.41
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$210.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,064.89
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$282.51
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$282.51
|
| Rate for Payer: Multiplan Commercial |
$3,993.34
|
| Rate for Payer: Networks By Design Commercial |
$2,662.22
|
| Rate for Payer: Prime Health Services Commercial |
$4,525.78
|
| Rate for Payer: Prime Health Services Medicare |
$223.48
|
| Rate for Payer: Riverside University Health MISP |
$231.91
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3,194.67
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3,194.67
|
| Rate for Payer: United Healthcare All Other Commercial |
$2,662.22
|
| Rate for Payer: United Healthcare All Other HMO |
$2,662.22
|
| Rate for Payer: United Healthcare HMO Rider |
$2,662.22
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2,662.22
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$316.24
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$231.91
|
| Rate for Payer: Vantage Medical Group Senior |
$210.83
|
|
|
OCTREOTIDE,MICROSPHERES 30 MG INTRAMUSCULR WRAP, LONG-ACTING RELEASE [40824436]
|
Facility
IP
|
$7,972.97
|
|
|
Service Code
|
CPT J2353
|
| Hospital Charge Code |
ERX24436
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,594.59 |
| Max. Negotiated Rate |
$7,175.67 |
| Rate for Payer: Blue Shield of California Commercial |
$5,979.73
|
| Rate for Payer: Blue Shield of California EPN |
$4,257.57
|
| Rate for Payer: Cash Price |
$3,587.84
|
| Rate for Payer: Central Health Plan Commercial |
$6,378.38
|
| Rate for Payer: Cigna of CA HMO |
$5,581.08
|
| Rate for Payer: Cigna of CA PPO |
$5,581.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,189.19
|
| Rate for Payer: EPIC Health Plan Transplant |
$3,189.19
|
| Rate for Payer: Galaxy Health WC |
$6,777.02
|
| Rate for Payer: Global Benefits Group Commercial |
$4,783.78
|
| Rate for Payer: Health Management Network EPO/PPO |
$7,175.67
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5,317.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,594.59
|
| Rate for Payer: Multiplan Commercial |
$5,979.73
|
| Rate for Payer: Networks By Design Commercial |
$3,986.48
|
| Rate for Payer: Prime Health Services Commercial |
$6,777.02
|
|
|
OCTREOTIDE,MICROSPHERES 30 MG INTRAMUSCULR WRAP, LONG-ACTING RELEASE [40824436]
|
Facility
OP
|
$7,972.97
|
|
|
Service Code
|
CPT J2353
|
| Hospital Charge Code |
ERX24436
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$160.99 |
| Max. Negotiated Rate |
$7,175.67 |
| Rate for Payer: Adventist Health Medi-Cal |
$210.83
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1,306.54
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$263.54
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$231.91
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$231.91
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$160.99
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$176.26
|
| Rate for Payer: BCBS Transplant Transplant |
$4,783.78
|
| Rate for Payer: Blue Shield of California Commercial |
$281.47
|
| Rate for Payer: Blue Shield of California EPN |
$255.88
|
| Rate for Payer: Caremore Medicare Advantage |
$210.83
|
| Rate for Payer: Cash Price |
$3,587.84
|
| Rate for Payer: Cash Price |
$3,587.84
|
| Rate for Payer: Central Health Plan Commercial |
$6,378.38
|
| Rate for Payer: Cigna of CA HMO |
$5,581.08
|
| Rate for Payer: Cigna of CA PPO |
$5,581.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$316.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$284.62
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$210.83
|
| Rate for Payer: EPIC Health Plan Transplant |
$210.83
|
| Rate for Payer: Galaxy Health WC |
$6,777.02
|
| Rate for Payer: Global Benefits Group Commercial |
$4,783.78
|
| Rate for Payer: Health Management Network EPO/PPO |
$7,175.67
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$5,979.73
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$345.76
|
| Rate for Payer: IEHP medi-cal |
$347.87
|
| Rate for Payer: IEHP Medicare Advantage |
$210.83
|
| Rate for Payer: Innovage PACE Commercial |
$316.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5,317.97
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$210.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,594.59
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$282.51
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$282.51
|
| Rate for Payer: Multiplan Commercial |
$5,979.73
|
| Rate for Payer: Networks By Design Commercial |
$3,986.48
|
| Rate for Payer: Prime Health Services Commercial |
$6,777.02
|
| Rate for Payer: Prime Health Services Medicare |
$223.48
|
| Rate for Payer: Riverside University Health MISP |
$231.91
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$4,783.78
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$4,783.78
|
| Rate for Payer: United Healthcare All Other Commercial |
$3,986.48
|
| Rate for Payer: United Healthcare All Other HMO |
$3,986.48
|
| Rate for Payer: United Healthcare HMO Rider |
$3,986.48
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3,986.48
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$316.24
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$231.91
|
| Rate for Payer: Vantage Medical Group Senior |
$210.83
|
|
|
OCTREOTIDE,MICROSPHERES ER 10 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE [204871]
|
Facility
IP
|
$4,063.93
|
|
|
Service Code
|
CPT J2353
|
| Hospital Charge Code |
ERX204871
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$812.79 |
| Max. Negotiated Rate |
$3,657.54 |
| Rate for Payer: Blue Shield of California Commercial |
$3,047.95
|
| Rate for Payer: Blue Shield of California EPN |
$2,170.14
|
| Rate for Payer: Cash Price |
$1,828.77
|
| Rate for Payer: Central Health Plan Commercial |
$3,251.14
|
| Rate for Payer: Cigna of CA HMO |
$2,844.75
|
| Rate for Payer: Cigna of CA PPO |
$2,844.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,625.57
|
| Rate for Payer: EPIC Health Plan Transplant |
$1,625.57
|
| Rate for Payer: Galaxy Health WC |
$3,454.34
|
| Rate for Payer: Global Benefits Group Commercial |
$2,438.36
|
| Rate for Payer: Health Management Network EPO/PPO |
$3,657.54
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2,710.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$812.79
|
| Rate for Payer: Multiplan Commercial |
$3,047.95
|
| Rate for Payer: Networks By Design Commercial |
$2,031.96
|
| Rate for Payer: Prime Health Services Commercial |
$3,454.34
|
|
|
OCTREOTIDE,MICROSPHERES ER 10 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE [204871]
|
Facility
OP
|
$4,063.93
|
|
|
Service Code
|
CPT J2353
|
| Hospital Charge Code |
ERX204871
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$160.99 |
| Max. Negotiated Rate |
$3,657.54 |
| Rate for Payer: Adventist Health Medi-Cal |
$210.83
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1,306.54
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$263.54
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$231.91
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$231.91
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$160.99
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$176.26
|
| Rate for Payer: BCBS Transplant Transplant |
$2,438.36
|
| Rate for Payer: Blue Shield of California Commercial |
$281.47
|
| Rate for Payer: Blue Shield of California EPN |
$255.88
|
| Rate for Payer: Caremore Medicare Advantage |
$210.83
|
| Rate for Payer: Cash Price |
$1,828.77
|
| Rate for Payer: Cash Price |
$1,828.77
|
| Rate for Payer: Central Health Plan Commercial |
$3,251.14
|
| Rate for Payer: Cigna of CA HMO |
$2,844.75
|
| Rate for Payer: Cigna of CA PPO |
$2,844.75
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$316.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$284.62
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$210.83
|
| Rate for Payer: EPIC Health Plan Transplant |
$210.83
|
| Rate for Payer: Galaxy Health WC |
$3,454.34
|
| Rate for Payer: Global Benefits Group Commercial |
$2,438.36
|
| Rate for Payer: Health Management Network EPO/PPO |
$3,657.54
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$3,047.95
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$345.76
|
| Rate for Payer: IEHP medi-cal |
$347.87
|
| Rate for Payer: IEHP Medicare Advantage |
$210.83
|
| Rate for Payer: Innovage PACE Commercial |
$316.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2,710.64
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$210.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$812.79
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$282.51
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$282.51
|
| Rate for Payer: Multiplan Commercial |
$3,047.95
|
| Rate for Payer: Networks By Design Commercial |
$2,031.96
|
| Rate for Payer: Prime Health Services Commercial |
$3,454.34
|
| Rate for Payer: Prime Health Services Medicare |
$223.48
|
| Rate for Payer: Riverside University Health MISP |
$231.91
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2,438.36
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2,438.36
|
| Rate for Payer: United Healthcare All Other Commercial |
$2,031.96
|
| Rate for Payer: United Healthcare All Other HMO |
$2,031.96
|
| Rate for Payer: United Healthcare HMO Rider |
$2,031.96
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2,031.96
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$316.24
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$231.91
|
| Rate for Payer: Vantage Medical Group Senior |
$210.83
|
|
|
OCTREOTIDE,MICROSPHERES ER 20 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE [204610]
|
Facility
OP
|
$5,324.45
|
|
|
Service Code
|
CPT J2353
|
| Hospital Charge Code |
1720927
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$160.99 |
| Max. Negotiated Rate |
$4,792.00 |
| Rate for Payer: Adventist Health Medi-Cal |
$210.83
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1,306.54
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$263.54
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$231.91
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$231.91
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$160.99
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$176.26
|
| Rate for Payer: BCBS Transplant Transplant |
$3,194.67
|
| Rate for Payer: Blue Shield of California Commercial |
$281.47
|
| Rate for Payer: Blue Shield of California EPN |
$255.88
|
| Rate for Payer: Caremore Medicare Advantage |
$210.83
|
| Rate for Payer: Cash Price |
$2,396.00
|
| Rate for Payer: Cash Price |
$2,396.00
|
| Rate for Payer: Central Health Plan Commercial |
$4,259.56
|
| Rate for Payer: Cigna of CA HMO |
$3,727.12
|
| Rate for Payer: Cigna of CA PPO |
$3,727.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$316.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$284.62
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$210.83
|
| Rate for Payer: EPIC Health Plan Transplant |
$210.83
|
| Rate for Payer: Galaxy Health WC |
$4,525.78
|
| Rate for Payer: Global Benefits Group Commercial |
$3,194.67
|
| Rate for Payer: Health Management Network EPO/PPO |
$4,792.00
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$3,993.34
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$345.76
|
| Rate for Payer: IEHP medi-cal |
$347.87
|
| Rate for Payer: IEHP Medicare Advantage |
$210.83
|
| Rate for Payer: Innovage PACE Commercial |
$316.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3,551.41
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$210.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,064.89
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$282.51
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$282.51
|
| Rate for Payer: Multiplan Commercial |
$3,993.34
|
| Rate for Payer: Networks By Design Commercial |
$2,662.22
|
| Rate for Payer: Prime Health Services Commercial |
$4,525.78
|
| Rate for Payer: Prime Health Services Medicare |
$223.48
|
| Rate for Payer: Riverside University Health MISP |
$231.91
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3,194.67
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3,194.67
|
| Rate for Payer: United Healthcare All Other Commercial |
$2,662.22
|
| Rate for Payer: United Healthcare All Other HMO |
$2,662.22
|
| Rate for Payer: United Healthcare HMO Rider |
$2,662.22
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2,662.22
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$316.24
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$231.91
|
| Rate for Payer: Vantage Medical Group Senior |
$210.83
|
|
|
OCTREOTIDE,MICROSPHERES ER 20 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE [204610]
|
Facility
IP
|
$5,324.45
|
|
|
Service Code
|
CPT J2353
|
| Hospital Charge Code |
1720927
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,064.89 |
| Max. Negotiated Rate |
$4,792.00 |
| Rate for Payer: Blue Shield of California Commercial |
$3,993.34
|
| Rate for Payer: Blue Shield of California EPN |
$2,843.26
|
| Rate for Payer: Cash Price |
$2,396.00
|
| Rate for Payer: Central Health Plan Commercial |
$4,259.56
|
| Rate for Payer: Cigna of CA HMO |
$3,727.12
|
| Rate for Payer: Cigna of CA PPO |
$3,727.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,129.78
|
| Rate for Payer: EPIC Health Plan Transplant |
$2,129.78
|
| Rate for Payer: Galaxy Health WC |
$4,525.78
|
| Rate for Payer: Global Benefits Group Commercial |
$3,194.67
|
| Rate for Payer: Health Management Network EPO/PPO |
$4,792.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3,551.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,064.89
|
| Rate for Payer: Multiplan Commercial |
$3,993.34
|
| Rate for Payer: Networks By Design Commercial |
$2,662.22
|
| Rate for Payer: Prime Health Services Commercial |
$4,525.78
|
|
|
OCTREOTIDE,MICROSPHERES ER 30 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE [204612]
|
Facility
IP
|
$7,972.97
|
|
|
Service Code
|
CPT J2353
|
| Hospital Charge Code |
ERX204612
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,594.59 |
| Max. Negotiated Rate |
$7,175.67 |
| Rate for Payer: Blue Shield of California Commercial |
$5,979.73
|
| Rate for Payer: Blue Shield of California EPN |
$4,257.57
|
| Rate for Payer: Cash Price |
$3,587.84
|
| Rate for Payer: Central Health Plan Commercial |
$6,378.38
|
| Rate for Payer: Cigna of CA HMO |
$5,581.08
|
| Rate for Payer: Cigna of CA PPO |
$5,581.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,189.19
|
| Rate for Payer: EPIC Health Plan Transplant |
$3,189.19
|
| Rate for Payer: Galaxy Health WC |
$6,777.02
|
| Rate for Payer: Global Benefits Group Commercial |
$4,783.78
|
| Rate for Payer: Health Management Network EPO/PPO |
$7,175.67
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5,317.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,594.59
|
| Rate for Payer: Multiplan Commercial |
$5,979.73
|
| Rate for Payer: Networks By Design Commercial |
$3,986.48
|
| Rate for Payer: Prime Health Services Commercial |
$6,777.02
|
|
|
OCTREOTIDE,MICROSPHERES ER 30 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE [204612]
|
Facility
OP
|
$7,972.97
|
|
|
Service Code
|
CPT J2353
|
| Hospital Charge Code |
ERX204612
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$160.99 |
| Max. Negotiated Rate |
$7,175.67 |
| Rate for Payer: Adventist Health Medi-Cal |
$210.83
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1,306.54
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$263.54
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$231.91
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$231.91
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$160.99
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$176.26
|
| Rate for Payer: BCBS Transplant Transplant |
$4,783.78
|
| Rate for Payer: Blue Shield of California Commercial |
$281.47
|
| Rate for Payer: Blue Shield of California EPN |
$255.88
|
| Rate for Payer: Caremore Medicare Advantage |
$210.83
|
| Rate for Payer: Cash Price |
$3,587.84
|
| Rate for Payer: Cash Price |
$3,587.84
|
| Rate for Payer: Central Health Plan Commercial |
$6,378.38
|
| Rate for Payer: Cigna of CA HMO |
$5,581.08
|
| Rate for Payer: Cigna of CA PPO |
$5,581.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$316.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$284.62
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$210.83
|
| Rate for Payer: EPIC Health Plan Transplant |
$210.83
|
| Rate for Payer: Galaxy Health WC |
$6,777.02
|
| Rate for Payer: Global Benefits Group Commercial |
$4,783.78
|
| Rate for Payer: Health Management Network EPO/PPO |
$7,175.67
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$5,979.73
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$345.76
|
| Rate for Payer: IEHP medi-cal |
$347.87
|
| Rate for Payer: IEHP Medicare Advantage |
$210.83
|
| Rate for Payer: Innovage PACE Commercial |
$316.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5,317.97
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$210.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,594.59
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$282.51
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$282.51
|
| Rate for Payer: Multiplan Commercial |
$5,979.73
|
| Rate for Payer: Networks By Design Commercial |
$3,986.48
|
| Rate for Payer: Prime Health Services Commercial |
$6,777.02
|
| Rate for Payer: Prime Health Services Medicare |
$223.48
|
| Rate for Payer: Riverside University Health MISP |
$231.91
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$4,783.78
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$4,783.78
|
| Rate for Payer: United Healthcare All Other Commercial |
$3,986.48
|
| Rate for Payer: United Healthcare All Other HMO |
$3,986.48
|
| Rate for Payer: United Healthcare HMO Rider |
$3,986.48
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3,986.48
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$316.24
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$231.91
|
| Rate for Payer: Vantage Medical Group Senior |
$210.83
|
|
|
OFLOXACIN 0.3 % EAR DROPS [22257]
|
Facility
OP
|
$3.60
|
|
|
Service Code
|
NDC 69238-1615-3
|
| Hospital Charge Code |
1740311
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.72 |
| Max. Negotiated Rate |
$3.24 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2.19
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3.06
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.98
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.98
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1.74
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.13
|
| Rate for Payer: BCBS Transplant Transplant |
$2.16
|
| Rate for Payer: Blue Shield of California Commercial |
$2.26
|
| Rate for Payer: Blue Shield of California EPN |
$1.76
|
| Rate for Payer: Cash Price |
$1.62
|
| Rate for Payer: Central Health Plan Commercial |
$2.88
|
| Rate for Payer: Cigna of CA HMO |
$2.52
|
| Rate for Payer: Cigna of CA PPO |
$2.52
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.44
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.44
|
| Rate for Payer: Galaxy Health WC |
$3.06
|
| Rate for Payer: Global Benefits Group Commercial |
$2.16
|
| Rate for Payer: Health Management Network EPO/PPO |
$3.24
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$2.70
|
| Rate for Payer: IEHP medi-cal |
$1.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.72
|
| Rate for Payer: Multiplan Commercial |
$2.70
|
| Rate for Payer: Networks By Design Commercial |
$2.34
|
| Rate for Payer: Prime Health Services Commercial |
$3.06
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$2.16
|
| Rate for Payer: Riverside University Health MISP |
$1.44
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.16
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.16
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.80
|
| Rate for Payer: United Healthcare All Other HMO |
$1.80
|
| Rate for Payer: United Healthcare HMO Rider |
$1.80
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.06
|
| Rate for Payer: Vantage Medical Group Senior |
$3.06
|
|
|
OFLOXACIN 0.3 % EAR DROPS [22257]
|
Facility
OP
|
$15.60
|
|
|
Service Code
|
NDC 60505-0363-1
|
| Hospital Charge Code |
1740311
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.12 |
| Max. Negotiated Rate |
$14.04 |
| Rate for Payer: Aetna of CA HMO/PPO |
$9.47
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$13.26
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$8.58
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$8.58
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$7.55
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9.22
|
| Rate for Payer: BCBS Transplant Transplant |
$9.36
|
| Rate for Payer: Blue Shield of California Commercial |
$9.81
|
| Rate for Payer: Blue Shield of California EPN |
$7.63
|
| Rate for Payer: Cash Price |
$7.02
|
| Rate for Payer: Central Health Plan Commercial |
$12.48
|
| Rate for Payer: Cigna of CA HMO |
$10.92
|
| Rate for Payer: Cigna of CA PPO |
$10.92
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$13.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.24
|
| Rate for Payer: EPIC Health Plan Transplant |
$6.24
|
| Rate for Payer: Galaxy Health WC |
$13.26
|
| Rate for Payer: Global Benefits Group Commercial |
$9.36
|
| Rate for Payer: Health Management Network EPO/PPO |
$14.04
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$11.70
|
| Rate for Payer: IEHP medi-cal |
$5.46
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$10.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.12
|
| Rate for Payer: Multiplan Commercial |
$11.70
|
| Rate for Payer: Networks By Design Commercial |
$10.14
|
| Rate for Payer: Prime Health Services Commercial |
$13.26
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$9.36
|
| Rate for Payer: Riverside University Health MISP |
$6.24
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$9.36
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$9.36
|
| Rate for Payer: United Healthcare All Other Commercial |
$7.80
|
| Rate for Payer: United Healthcare All Other HMO |
$7.80
|
| Rate for Payer: United Healthcare HMO Rider |
$7.80
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$7.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$13.26
|
| Rate for Payer: Vantage Medical Group Senior |
$13.26
|
|
|
OFLOXACIN 0.3 % EAR DROPS [22257]
|
Facility
IP
|
$3.60
|
|
|
Service Code
|
NDC 69238-1615-3
|
| Hospital Charge Code |
1740311
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.72 |
| Max. Negotiated Rate |
$3.24 |
| Rate for Payer: Blue Shield of California Commercial |
$2.70
|
| Rate for Payer: Blue Shield of California EPN |
$1.92
|
| Rate for Payer: Cash Price |
$1.62
|
| Rate for Payer: Central Health Plan Commercial |
$2.88
|
| Rate for Payer: Cigna of CA HMO |
$2.52
|
| Rate for Payer: Cigna of CA PPO |
$2.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.44
|
| Rate for Payer: Galaxy Health WC |
$3.06
|
| Rate for Payer: Global Benefits Group Commercial |
$2.16
|
| Rate for Payer: Health Management Network EPO/PPO |
$3.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.72
|
| Rate for Payer: Multiplan Commercial |
$2.70
|
| Rate for Payer: Networks By Design Commercial |
$2.34
|
| Rate for Payer: Prime Health Services Commercial |
$3.06
|
|
|
OFLOXACIN 0.3 % EAR DROPS [22257]
|
Facility
OP
|
$15.60
|
|
|
Service Code
|
NDC 50383-025-05
|
| Hospital Charge Code |
1740311
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.12 |
| Max. Negotiated Rate |
$14.04 |
| Rate for Payer: Aetna of CA HMO/PPO |
$9.47
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$13.26
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$8.58
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$8.58
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$7.55
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9.22
|
| Rate for Payer: BCBS Transplant Transplant |
$9.36
|
| Rate for Payer: Blue Shield of California Commercial |
$9.81
|
| Rate for Payer: Blue Shield of California EPN |
$7.63
|
| Rate for Payer: Cash Price |
$7.02
|
| Rate for Payer: Central Health Plan Commercial |
$12.48
|
| Rate for Payer: Cigna of CA HMO |
$10.92
|
| Rate for Payer: Cigna of CA PPO |
$10.92
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$13.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.24
|
| Rate for Payer: EPIC Health Plan Transplant |
$6.24
|
| Rate for Payer: Galaxy Health WC |
$13.26
|
| Rate for Payer: Global Benefits Group Commercial |
$9.36
|
| Rate for Payer: Health Management Network EPO/PPO |
$14.04
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$11.70
|
| Rate for Payer: IEHP medi-cal |
$5.46
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$10.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.12
|
| Rate for Payer: Multiplan Commercial |
$11.70
|
| Rate for Payer: Networks By Design Commercial |
$10.14
|
| Rate for Payer: Prime Health Services Commercial |
$13.26
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$9.36
|
| Rate for Payer: Riverside University Health MISP |
$6.24
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$9.36
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$9.36
|
| Rate for Payer: United Healthcare All Other Commercial |
$7.80
|
| Rate for Payer: United Healthcare All Other HMO |
$7.80
|
| Rate for Payer: United Healthcare HMO Rider |
$7.80
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$7.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$13.26
|
| Rate for Payer: Vantage Medical Group Senior |
$13.26
|
|
|
OFLOXACIN 0.3 % EAR DROPS [22257]
|
Facility
OP
|
$30.86
|
|
|
Service Code
|
NDC 24208-410-05
|
| Hospital Charge Code |
1740311
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.17 |
| Max. Negotiated Rate |
$27.77 |
| Rate for Payer: Aetna of CA HMO/PPO |
$18.74
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$26.23
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$16.97
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$16.97
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$14.94
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$18.23
|
| Rate for Payer: BCBS Transplant Transplant |
$18.52
|
| Rate for Payer: Blue Shield of California Commercial |
$19.41
|
| Rate for Payer: Blue Shield of California EPN |
$15.09
|
| Rate for Payer: Cash Price |
$13.89
|
| Rate for Payer: Central Health Plan Commercial |
$24.69
|
| Rate for Payer: Cigna of CA HMO |
$21.60
|
| Rate for Payer: Cigna of CA PPO |
$21.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$26.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.34
|
| Rate for Payer: EPIC Health Plan Transplant |
$12.34
|
| Rate for Payer: Galaxy Health WC |
$26.23
|
| Rate for Payer: Global Benefits Group Commercial |
$18.52
|
| Rate for Payer: Health Management Network EPO/PPO |
$27.77
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$23.14
|
| Rate for Payer: IEHP medi-cal |
$10.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$20.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.17
|
| Rate for Payer: Multiplan Commercial |
$23.14
|
| Rate for Payer: Networks By Design Commercial |
$20.06
|
| Rate for Payer: Prime Health Services Commercial |
$26.23
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$18.52
|
| Rate for Payer: Riverside University Health MISP |
$12.34
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$18.52
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$18.52
|
| Rate for Payer: United Healthcare All Other Commercial |
$15.43
|
| Rate for Payer: United Healthcare All Other HMO |
$15.43
|
| Rate for Payer: United Healthcare HMO Rider |
$15.43
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$15.43
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$26.23
|
| Rate for Payer: Vantage Medical Group Senior |
$26.23
|
|
|
OFLOXACIN 0.3 % EAR DROPS [22257]
|
Facility
IP
|
$15.60
|
|
|
Service Code
|
NDC 50383-025-05
|
| Hospital Charge Code |
1740311
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.12 |
| Max. Negotiated Rate |
$14.04 |
| Rate for Payer: Blue Shield of California Commercial |
$11.70
|
| Rate for Payer: Blue Shield of California EPN |
$8.33
|
| Rate for Payer: Cash Price |
$7.02
|
| Rate for Payer: Central Health Plan Commercial |
$12.48
|
| Rate for Payer: Cigna of CA HMO |
$10.92
|
| Rate for Payer: Cigna of CA PPO |
$10.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.24
|
| Rate for Payer: Galaxy Health WC |
$13.26
|
| Rate for Payer: Global Benefits Group Commercial |
$9.36
|
| Rate for Payer: Health Management Network EPO/PPO |
$14.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$10.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.12
|
| Rate for Payer: Multiplan Commercial |
$11.70
|
| Rate for Payer: Networks By Design Commercial |
$10.14
|
| Rate for Payer: Prime Health Services Commercial |
$13.26
|
|
|
OFLOXACIN 0.3 % EAR DROPS [22257]
|
Facility
IP
|
$30.86
|
|
|
Service Code
|
NDC 24208-410-05
|
| Hospital Charge Code |
1740311
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.17 |
| Max. Negotiated Rate |
$27.77 |
| Rate for Payer: Blue Shield of California Commercial |
$23.14
|
| Rate for Payer: Blue Shield of California EPN |
$16.48
|
| Rate for Payer: Cash Price |
$13.89
|
| Rate for Payer: Central Health Plan Commercial |
$24.69
|
| Rate for Payer: Cigna of CA HMO |
$21.60
|
| Rate for Payer: Cigna of CA PPO |
$21.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.34
|
| Rate for Payer: Galaxy Health WC |
$26.23
|
| Rate for Payer: Global Benefits Group Commercial |
$18.52
|
| Rate for Payer: Health Management Network EPO/PPO |
$27.77
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$20.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.17
|
| Rate for Payer: Multiplan Commercial |
$23.14
|
| Rate for Payer: Networks By Design Commercial |
$20.06
|
| Rate for Payer: Prime Health Services Commercial |
$26.23
|
|
|
OFLOXACIN 0.3 % EAR DROPS [22257]
|
Facility
IP
|
$15.60
|
|
|
Service Code
|
NDC 60505-0363-1
|
| Hospital Charge Code |
1740311
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.12 |
| Max. Negotiated Rate |
$14.04 |
| Rate for Payer: Blue Shield of California Commercial |
$11.70
|
| Rate for Payer: Blue Shield of California EPN |
$8.33
|
| Rate for Payer: Cash Price |
$7.02
|
| Rate for Payer: Central Health Plan Commercial |
$12.48
|
| Rate for Payer: Cigna of CA HMO |
$10.92
|
| Rate for Payer: Cigna of CA PPO |
$10.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.24
|
| Rate for Payer: Galaxy Health WC |
$13.26
|
| Rate for Payer: Global Benefits Group Commercial |
$9.36
|
| Rate for Payer: Health Management Network EPO/PPO |
$14.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$10.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.12
|
| Rate for Payer: Multiplan Commercial |
$11.70
|
| Rate for Payer: Networks By Design Commercial |
$10.14
|
| Rate for Payer: Prime Health Services Commercial |
$13.26
|
|
|
OFLOXACIN 0.3 % EYE DROPS [19746]
|
Facility
OP
|
$4.91
|
|
|
Service Code
|
NDC 24208-434-05
|
| Hospital Charge Code |
1740303
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.98 |
| Max. Negotiated Rate |
$4.42 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2.98
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$4.17
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.70
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.70
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$2.38
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.90
|
| Rate for Payer: BCBS Transplant Transplant |
$2.95
|
| Rate for Payer: Blue Shield of California Commercial |
$3.09
|
| Rate for Payer: Blue Shield of California EPN |
$2.40
|
| Rate for Payer: Cash Price |
$2.21
|
| Rate for Payer: Central Health Plan Commercial |
$3.93
|
| Rate for Payer: Cigna of CA HMO |
$3.44
|
| Rate for Payer: Cigna of CA PPO |
$3.44
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.96
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.96
|
| Rate for Payer: Galaxy Health WC |
$4.17
|
| Rate for Payer: Global Benefits Group Commercial |
$2.95
|
| Rate for Payer: Health Management Network EPO/PPO |
$4.42
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$3.68
|
| Rate for Payer: IEHP medi-cal |
$1.72
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.98
|
| Rate for Payer: Multiplan Commercial |
$3.68
|
| Rate for Payer: Networks By Design Commercial |
$3.19
|
| Rate for Payer: Prime Health Services Commercial |
$4.17
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$2.95
|
| Rate for Payer: Riverside University Health MISP |
$1.96
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.95
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.95
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.46
|
| Rate for Payer: United Healthcare All Other HMO |
$2.46
|
| Rate for Payer: United Healthcare HMO Rider |
$2.46
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.46
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.17
|
| Rate for Payer: Vantage Medical Group Senior |
$4.17
|
|
|
OFLOXACIN 0.3 % EYE DROPS [19746]
|
Facility
IP
|
$3.60
|
|
|
Service Code
|
NDC 64980-515-05
|
| Hospital Charge Code |
1740303
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.72 |
| Max. Negotiated Rate |
$3.24 |
| Rate for Payer: Blue Shield of California Commercial |
$2.70
|
| Rate for Payer: Blue Shield of California EPN |
$1.92
|
| Rate for Payer: Cash Price |
$1.62
|
| Rate for Payer: Central Health Plan Commercial |
$2.88
|
| Rate for Payer: Cigna of CA HMO |
$2.52
|
| Rate for Payer: Cigna of CA PPO |
$2.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.44
|
| Rate for Payer: Galaxy Health WC |
$3.06
|
| Rate for Payer: Global Benefits Group Commercial |
$2.16
|
| Rate for Payer: Health Management Network EPO/PPO |
$3.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.72
|
| Rate for Payer: Multiplan Commercial |
$2.70
|
| Rate for Payer: Networks By Design Commercial |
$2.34
|
| Rate for Payer: Prime Health Services Commercial |
$3.06
|
|
