|
POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET [25424]
|
Facility
|
IP
|
$1.06
|
|
|
Service Code
|
NDC 9999-9321-54
|
| 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 |
$0.82
|
| Rate for Payer: Blue Shield of California EPN |
$0.53
|
| Rate for Payer: Cash Price |
$0.58
|
| 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: 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 Permanente of CA Commercial/Self Funded |
$0.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.40
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.21
|
| 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
|
|
|
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 |
$0.39
|
| Rate for Payer: Blue Shield of California EPN |
$0.26
|
| Rate for Payer: Cash Price |
$0.28
|
| 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: 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 Permanente of CA Commercial/Self Funded |
$0.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.32
|
| 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
|
|
|
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 |
$0.31
|
| Rate for Payer: Blue Shield of California EPN |
$0.20
|
| Rate for Payer: Cash Price |
$0.28
|
| 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: 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: InnovAge PACE Commercial |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.36
|
| Rate for Payer: Molina Healthcare of CA 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
|
|
|
POLYMYXIN B SULFATE 10,000 UNIT-TRIMETHOPRIM 1 MG/ML EYE DROPS [111465]
|
Facility
|
OP
|
$1.24
|
|
|
Service Code
|
NDC 61314-628-10
|
| 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 |
$0.73
|
| Rate for Payer: Blue Shield of California Commercial |
$0.76
|
| Rate for Payer: Blue Shield of California EPN |
$0.49
|
| Rate for Payer: Cash Price |
$0.68
|
| 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: 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: InnovAge PACE Commercial |
$0.62
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.83
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.47
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.77
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.87
|
| Rate for Payer: Molina Healthcare of CA 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 61314-628-10
|
| 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 |
$0.96
|
| Rate for Payer: Blue Shield of California EPN |
$0.62
|
| Rate for Payer: Cash Price |
$0.68
|
| 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: 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 Permanente of CA Commercial/Self Funded |
$0.83
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.47
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.77
|
| 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
|
IP
|
$12.00
|
|
|
Service Code
|
NDC 55150-234-10
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| 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 |
$9.28
|
| Rate for Payer: Blue Shield of California EPN |
$6.05
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Central Health Plan Commercial |
$9.60
|
| 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 Permanente of CA Commercial/Self Funded |
$8.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.57
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$7.43
|
| 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 |
$7.80
|
| Rate for Payer: Prime Health Services Commercial |
$10.20
|
|
|
POLYMYXIN B SULFATE 500,000 UNIT SOLUTION FOR INJECTION [6393]
|
Facility
|
OP
|
$12.00
|
|
|
Service Code
|
NDC 55150-234-10
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| 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: Anthem Blue Cross of CA Exchange |
$5.81
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7.05
|
| Rate for Payer: Blue Shield of California Commercial |
$7.33
|
| Rate for Payer: Blue Shield of California EPN |
$4.79
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Central Health Plan Commercial |
$9.60
|
| Rate for Payer: Cigna of CA HMO |
$7.68
|
| Rate for Payer: Cigna of CA PPO |
$8.88
|
| 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: 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: InnovAge PACE Commercial |
$6.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$8.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.57
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$7.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.40
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$8.40
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$8.40
|
| Rate for Payer: Multiplan Commercial |
$9.00
|
| Rate for Payer: Networks By Design Commercial |
$7.80
|
| 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 |
$6.00
|
| Rate for Payer: United Healthcare All Other HMO |
$6.00
|
| Rate for Payer: United Healthcare HMO Rider |
$6.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6.00
|
| 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
|
|
|
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 |
$1.34
|
| Rate for Payer: Blue Shield of California EPN |
$0.87
|
| Rate for Payer: Cash Price |
$0.95
|
| 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: 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 Permanente of CA Commercial/Self Funded |
$1.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.66
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.07
|
| 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 |
$1.02
|
| Rate for Payer: Blue Shield of California Commercial |
$1.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.69
|
| Rate for Payer: Cash Price |
$0.95
|
| 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: 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: InnovAge PACE Commercial |
$0.87
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.66
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.35
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.21
|
| Rate for Payer: Molina Healthcare of CA 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
|
$479.17
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$95.83 |
| Max. Negotiated Rate |
$431.25 |
| Rate for Payer: Adventist Health Commercial |
$95.83
|
| Rate for Payer: Aetna of CA HMO/PPO |
$291.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$407.29
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$263.54
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$359.38
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$232.01
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$281.42
|
| Rate for Payer: Blue Shield of California Commercial |
$292.77
|
| Rate for Payer: Blue Shield of California EPN |
$191.19
|
| Rate for Payer: Cash Price |
$263.54
|
| Rate for Payer: Central Health Plan Commercial |
$383.34
|
| Rate for Payer: Cigna of CA HMO |
$335.42
|
| Rate for Payer: Cigna of CA PPO |
$335.42
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$407.29
|
| Rate for Payer: Dignity Health Medi-Cal |
$407.29
|
| Rate for Payer: Dignity Health Medicare Advantage |
$407.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$191.67
|
| Rate for Payer: EPIC Health Plan Senior |
$191.67
|
| Rate for Payer: Galaxy Health WC |
$407.29
|
| Rate for Payer: Global Benefits Group Commercial |
$287.50
|
| Rate for Payer: Health Management Network EPO/PPO |
$431.25
|
| Rate for Payer: InnovAge PACE Commercial |
$239.59
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$319.61
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$296.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$95.83
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$335.42
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$335.42
|
| Rate for Payer: Multiplan Commercial |
$359.38
|
| Rate for Payer: Networks By Design Commercial |
$239.59
|
| Rate for Payer: Prime Health Services Commercial |
$407.29
|
| Rate for Payer: Riverside University Health System MISP |
$191.67
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$287.50
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$287.50
|
| Rate for Payer: United Healthcare All Other Commercial |
$179.83
|
| Rate for Payer: United Healthcare All Other HMO |
$175.04
|
| Rate for Payer: United Healthcare HMO Rider |
$171.26
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$156.93
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$407.29
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$407.29
|
| Rate for Payer: Vantage Medical Group Senior |
$407.29
|
|
|
PORACTANT ALFA 120 MG/1.5 ML INTRATRACHEAL SUSPENSION [27047]
|
Facility
|
IP
|
$479.17
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$95.83 |
| Max. Negotiated Rate |
$431.25 |
| Rate for Payer: Adventist Health Commercial |
$95.83
|
| Rate for Payer: Blue Shield of California Commercial |
$370.40
|
| Rate for Payer: Blue Shield of California EPN |
$241.50
|
| Rate for Payer: Cash Price |
$263.54
|
| Rate for Payer: Central Health Plan Commercial |
$383.34
|
| Rate for Payer: Cigna of CA HMO |
$335.42
|
| Rate for Payer: Cigna of CA PPO |
$335.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$191.67
|
| Rate for Payer: EPIC Health Plan Senior |
$191.67
|
| Rate for Payer: Galaxy Health WC |
$407.29
|
| Rate for Payer: Global Benefits Group Commercial |
$287.50
|
| Rate for Payer: Health Management Network EPO/PPO |
$431.25
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$319.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$182.56
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$296.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$95.83
|
| Rate for Payer: Multiplan Commercial |
$359.38
|
| Rate for Payer: Networks By Design Commercial |
$239.59
|
| Rate for Payer: Prime Health Services Commercial |
$407.29
|
| Rate for Payer: United Healthcare All Other Commercial |
$179.83
|
| Rate for Payer: United Healthcare All Other HMO |
$175.04
|
| Rate for Payer: United Healthcare HMO Rider |
$171.26
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$156.93
|
|
|
PORACTANT ALFA 240 MG/3 ML INTRATRACHEAL SUSPENSION [117872]
|
Facility
|
OP
|
$472.43
|
|
|
Service Code
|
NDC 10122-510-03
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$94.49 |
| Max. Negotiated Rate |
$425.19 |
| Rate for Payer: Adventist Health Commercial |
$94.49
|
| Rate for Payer: Aetna of CA HMO/PPO |
$286.91
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$401.57
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$259.84
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$354.32
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$228.75
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$277.46
|
| Rate for Payer: Blue Shield of California Commercial |
$288.65
|
| Rate for Payer: Blue Shield of California EPN |
$188.50
|
| Rate for Payer: Cash Price |
$259.84
|
| Rate for Payer: Central Health Plan Commercial |
$377.94
|
| Rate for Payer: Cigna of CA HMO |
$302.36
|
| Rate for Payer: Cigna of CA PPO |
$349.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$401.57
|
| Rate for Payer: Dignity Health Medi-Cal |
$401.57
|
| Rate for Payer: Dignity Health Medicare Advantage |
$401.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$188.97
|
| Rate for Payer: EPIC Health Plan Senior |
$188.97
|
| Rate for Payer: Galaxy Health WC |
$401.57
|
| Rate for Payer: Global Benefits Group Commercial |
$283.46
|
| Rate for Payer: Health Management Network EPO/PPO |
$425.19
|
| Rate for Payer: InnovAge PACE Commercial |
$236.22
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$315.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$180.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$292.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$94.49
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$330.70
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$330.70
|
| Rate for Payer: Multiplan Commercial |
$354.32
|
| Rate for Payer: Networks By Design Commercial |
$307.08
|
| Rate for Payer: Prime Health Services Commercial |
$401.57
|
| Rate for Payer: Riverside University Health System MISP |
$188.97
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$283.46
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$283.46
|
| Rate for Payer: United Healthcare All Other Commercial |
$236.22
|
| Rate for Payer: United Healthcare All Other HMO |
$236.22
|
| Rate for Payer: United Healthcare HMO Rider |
$236.22
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$236.22
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$401.57
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$401.57
|
| Rate for Payer: Vantage Medical Group Senior |
$401.57
|
|
|
PORACTANT ALFA 240 MG/3 ML INTRATRACHEAL SUSPENSION [117872]
|
Facility
|
IP
|
$472.43
|
|
|
Service Code
|
NDC 10122-510-03
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$94.49 |
| Max. Negotiated Rate |
$425.19 |
| Rate for Payer: Adventist Health Commercial |
$94.49
|
| Rate for Payer: Blue Shield of California Commercial |
$365.19
|
| Rate for Payer: Blue Shield of California EPN |
$238.10
|
| Rate for Payer: Cash Price |
$259.84
|
| Rate for Payer: Central Health Plan Commercial |
$377.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$188.97
|
| Rate for Payer: EPIC Health Plan Senior |
$188.97
|
| Rate for Payer: Galaxy Health WC |
$401.57
|
| Rate for Payer: Global Benefits Group Commercial |
$283.46
|
| Rate for Payer: Health Management Network EPO/PPO |
$425.19
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$315.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$180.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$292.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$94.49
|
| Rate for Payer: Multiplan Commercial |
$354.32
|
| Rate for Payer: Networks By Design Commercial |
$307.08
|
| Rate for Payer: Prime Health Services Commercial |
$401.57
|
|
|
POSACONAZOLE 100 MG TABLET,DELAYED RELEASE [204306]
|
Facility
|
IP
|
$9.00
|
|
|
Service Code
|
NDC 72319-023-02
|
| 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 |
$6.96
|
| Rate for Payer: Blue Shield of California EPN |
$4.54
|
| Rate for Payer: Cash Price |
$4.95
|
| 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: 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 Permanente of CA Commercial/Self Funded |
$6.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.43
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5.57
|
| 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
|
$59.25
|
|
|
Service Code
|
NDC 0904-7149-04
|
| 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 |
$45.80
|
| Rate for Payer: Blue Shield of California EPN |
$29.86
|
| Rate for Payer: Cash Price |
$32.59
|
| 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: 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 Permanente of CA Commercial/Self Funded |
$39.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$22.57
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$36.68
|
| 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
|
OP
|
$9.00
|
|
|
Service Code
|
NDC 70748-258-07
|
| 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 |
$5.29
|
| Rate for Payer: Blue Shield of California Commercial |
$5.50
|
| Rate for Payer: Blue Shield of California EPN |
$3.59
|
| Rate for Payer: Cash Price |
$4.95
|
| 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: 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: InnovAge PACE Commercial |
$4.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$6.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.43
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.80
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$6.30
|
| Rate for Payer: Molina Healthcare of CA 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
|
|
|
POSACONAZOLE 100 MG TABLET,DELAYED RELEASE [204306]
|
Facility
|
OP
|
$9.00
|
|
|
Service Code
|
NDC 72319-023-02
|
| 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 |
$5.29
|
| Rate for Payer: Blue Shield of California Commercial |
$5.50
|
| Rate for Payer: Blue Shield of California EPN |
$3.59
|
| Rate for Payer: Cash Price |
$4.95
|
| 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: 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: InnovAge PACE Commercial |
$4.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$6.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.43
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.80
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$6.30
|
| Rate for Payer: Molina Healthcare of CA 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
|
|
|
POSACONAZOLE 100 MG TABLET,DELAYED RELEASE [204306]
|
Facility
|
IP
|
$9.00
|
|
|
Service Code
|
NDC 70748-258-07
|
| 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 |
$6.96
|
| Rate for Payer: Blue Shield of California EPN |
$4.54
|
| Rate for Payer: Cash Price |
$4.95
|
| 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: 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 Permanente of CA Commercial/Self Funded |
$6.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.43
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5.57
|
| 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
|
$59.25
|
|
|
Service Code
|
NDC 0904-7149-04
|
| 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 |
$34.80
|
| Rate for Payer: Blue Shield of California Commercial |
$36.20
|
| Rate for Payer: Blue Shield of California EPN |
$23.64
|
| Rate for Payer: Cash Price |
$32.59
|
| 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: 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: InnovAge PACE Commercial |
$29.62
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$39.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$22.57
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$36.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.85
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$41.48
|
| Rate for Payer: Molina Healthcare of CA 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 0527-2133-35
|
| 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 |
$3.87
|
| Rate for Payer: Blue Shield of California EPN |
$2.52
|
| Rate for Payer: Cash Price |
$2.75
|
| 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: 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 Permanente of CA Commercial/Self Funded |
$3.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.91
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3.10
|
| 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 0527-2133-35
|
| 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 |
$2.94
|
| Rate for Payer: Blue Shield of California Commercial |
$3.06
|
| Rate for Payer: Blue Shield of California EPN |
$2.00
|
| Rate for Payer: Cash Price |
$2.75
|
| 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: 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: InnovAge PACE Commercial |
$2.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.91
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3.50
|
| Rate for Payer: Molina Healthcare of CA 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 200 MG/5 ML (40 MG/ML) ORAL SUSPENSION [77371]
|
Facility
|
IP
|
$16.45
|
|
|
Service Code
|
NDC 0085-1328-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.29 |
| Max. Negotiated Rate |
$14.80 |
| Rate for Payer: Adventist Health Commercial |
$3.29
|
| Rate for Payer: Blue Shield of California Commercial |
$12.72
|
| Rate for Payer: Blue Shield of California EPN |
$8.29
|
| Rate for Payer: Cash Price |
$9.05
|
| Rate for Payer: Central Health Plan Commercial |
$13.16
|
| Rate for Payer: Cigna of CA HMO |
$11.52
|
| Rate for Payer: Cigna of CA PPO |
$11.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.58
|
| Rate for Payer: EPIC Health Plan Senior |
$6.58
|
| Rate for Payer: Galaxy Health WC |
$13.98
|
| Rate for Payer: Global Benefits Group Commercial |
$9.87
|
| Rate for Payer: Health Management Network EPO/PPO |
$14.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$10.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.27
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$10.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.29
|
| Rate for Payer: Multiplan Commercial |
$12.34
|
| Rate for Payer: Networks By Design Commercial |
$10.69
|
| Rate for Payer: Prime Health Services Commercial |
$13.98
|
|
|
POSACONAZOLE 200 MG/5 ML (40 MG/ML) ORAL SUSPENSION [77371]
|
Facility
|
OP
|
$16.45
|
|
|
Service Code
|
NDC 0085-1328-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.29 |
| Max. Negotiated Rate |
$14.80 |
| Rate for Payer: Adventist Health Commercial |
$3.29
|
| Rate for Payer: Aetna of CA HMO/PPO |
$9.99
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$13.98
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$9.05
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$12.34
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$7.97
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9.66
|
| Rate for Payer: Blue Shield of California Commercial |
$10.05
|
| Rate for Payer: Blue Shield of California EPN |
$6.56
|
| Rate for Payer: Cash Price |
$9.05
|
| Rate for Payer: Central Health Plan Commercial |
$13.16
|
| Rate for Payer: Cigna of CA HMO |
$11.52
|
| Rate for Payer: Cigna of CA PPO |
$11.52
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$13.98
|
| Rate for Payer: Dignity Health Medi-Cal |
$13.98
|
| Rate for Payer: Dignity Health Medicare Advantage |
$13.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.58
|
| Rate for Payer: EPIC Health Plan Senior |
$6.58
|
| Rate for Payer: Galaxy Health WC |
$13.98
|
| Rate for Payer: Global Benefits Group Commercial |
$9.87
|
| Rate for Payer: Health Management Network EPO/PPO |
$14.80
|
| Rate for Payer: InnovAge PACE Commercial |
$8.22
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$10.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.27
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$10.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.29
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$11.52
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$11.52
|
| Rate for Payer: Multiplan Commercial |
$12.34
|
| Rate for Payer: Networks By Design Commercial |
$10.69
|
| Rate for Payer: Prime Health Services Commercial |
$13.98
|
| Rate for Payer: Riverside University Health System MISP |
$6.58
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$9.87
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$9.87
|
| Rate for Payer: United Healthcare All Other Commercial |
$8.22
|
| Rate for Payer: United Healthcare All Other HMO |
$8.22
|
| Rate for Payer: United Healthcare HMO Rider |
$8.22
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$8.22
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$13.98
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$13.98
|
| Rate for Payer: Vantage Medical Group Senior |
$13.98
|
|
|
POSACONAZOLE 300 MG/16.7 ML INTRAVENOUS SOLUTION [205239]
|
Facility
|
IP
|
$36.21
|
|
|
Service Code
|
NDC 67457-665-20
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.24 |
| Max. Negotiated Rate |
$32.59 |
| Rate for Payer: Adventist Health Commercial |
$7.24
|
| Rate for Payer: Blue Shield of California Commercial |
$27.99
|
| Rate for Payer: Blue Shield of California EPN |
$18.25
|
| Rate for Payer: Cash Price |
$19.92
|
| Rate for Payer: Central Health Plan Commercial |
$28.97
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.48
|
| Rate for Payer: EPIC Health Plan Senior |
$14.48
|
| Rate for Payer: Galaxy Health WC |
$30.78
|
| Rate for Payer: Global Benefits Group Commercial |
$21.73
|
| Rate for Payer: Health Management Network EPO/PPO |
$32.59
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$24.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$13.80
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$22.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.24
|
| Rate for Payer: Multiplan Commercial |
$27.16
|
| Rate for Payer: Networks By Design Commercial |
$23.54
|
| Rate for Payer: Prime Health Services Commercial |
$30.78
|
|
|
POSACONAZOLE 300 MG/16.7 ML INTRAVENOUS SOLUTION [205239]
|
Facility
|
IP
|
$38.12
|
|
|
Service Code
|
NDC 0085-4331-01
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.62 |
| Max. Negotiated Rate |
$34.31 |
| Rate for Payer: Adventist Health Commercial |
$7.62
|
| Rate for Payer: Blue Shield of California Commercial |
$29.47
|
| Rate for Payer: Blue Shield of California EPN |
$19.21
|
| Rate for Payer: Cash Price |
$20.96
|
| Rate for Payer: Central Health Plan Commercial |
$30.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$15.25
|
| Rate for Payer: EPIC Health Plan Senior |
$15.25
|
| Rate for Payer: Galaxy Health WC |
$32.40
|
| Rate for Payer: Global Benefits Group Commercial |
$22.87
|
| Rate for Payer: Health Management Network EPO/PPO |
$34.31
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$25.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$14.52
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$23.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.62
|
| Rate for Payer: Multiplan Commercial |
$28.59
|
| Rate for Payer: Networks By Design Commercial |
$24.78
|
| Rate for Payer: Prime Health Services Commercial |
$32.40
|
|
