|
POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET [25424]
|
Facility
|
IP
|
$1.92
|
|
|
Service Code
|
NDC 60687-431-92
|
| Hospital Charge Code |
1713118
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.38 |
| Max. Negotiated Rate |
$1.73 |
| Rate for Payer: Blue Shield of California Commercial |
$1.44
|
| Rate for Payer: Blue Shield of California EPN |
$1.03
|
| Rate for Payer: Cash Price |
$0.86
|
| Rate for Payer: Central Health Plan Commercial |
$1.54
|
| Rate for Payer: Cigna of CA HMO |
$1.34
|
| Rate for Payer: Cigna of CA PPO |
$1.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.77
|
| Rate for Payer: Galaxy Health WC |
$1.63
|
| Rate for Payer: Global Benefits Group Commercial |
$1.15
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.73
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.38
|
| Rate for Payer: Multiplan Commercial |
$1.44
|
| Rate for Payer: Networks By Design Commercial |
$1.25
|
| Rate for Payer: Prime Health Services Commercial |
$1.63
|
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET [25424]
|
Facility
|
OP
|
$1.06
|
|
|
Service Code
|
NDC 9999-9321-54
|
| Hospital Charge Code |
1719218
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$0.95 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.64
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.90
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.58
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.58
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.51
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.63
|
| Rate for Payer: Blue Distinction Transplant |
$0.64
|
| Rate for Payer: Blue Shield of California Commercial |
$0.67
|
| Rate for Payer: Blue Shield of California EPN |
$0.52
|
| Rate for Payer: Cash Price |
$0.48
|
| Rate for Payer: Central Health Plan Commercial |
$0.85
|
| Rate for Payer: Cigna of CA HMO |
$0.74
|
| Rate for Payer: Cigna of CA PPO |
$0.74
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.90
|
| Rate for Payer: Dignity Health Media |
$0.90
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.42
|
| Rate for Payer: EPIC Health Plan Transplant |
$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: Health Plan of Nevada (Sierra) Other |
$0.80
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$0.37
|
| 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: 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
|
| Rate for Payer: Riverside University Health System MISP |
$0.42
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.64
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.64
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.53
|
| Rate for Payer: United Healthcare All Other HMO |
$0.53
|
| Rate for Payer: United Healthcare HMO Rider |
$0.53
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.53
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.90
|
| Rate for Payer: Vantage Medical Group Senior |
$0.90
|
|
|
POLYETHYLENE GLYCOL 3350 4.25 GRAM ORAL POWDER PACKET [232762]
|
Facility
|
OP
|
$1.37
|
|
|
Service Code
|
NDC 17856-0962-2
|
| Hospital Charge Code |
ERX232762
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$1.23 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.83
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.16
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.75
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.75
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.66
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.81
|
| Rate for Payer: Blue Distinction Transplant |
$0.82
|
| Rate for Payer: Blue Shield of California Commercial |
$0.86
|
| Rate for Payer: Blue Shield of California EPN |
$0.67
|
| Rate for Payer: Cash Price |
$0.62
|
| Rate for Payer: Central Health Plan Commercial |
$1.10
|
| Rate for Payer: Cigna of CA HMO |
$0.96
|
| Rate for Payer: Cigna of CA PPO |
$0.96
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.16
|
| Rate for Payer: Dignity Health Media |
$1.16
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.55
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.55
|
| Rate for Payer: Galaxy Health WC |
$1.16
|
| Rate for Payer: Global Benefits Group Commercial |
$0.82
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.23
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$1.03
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$0.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.27
|
| Rate for Payer: Multiplan Commercial |
$1.03
|
| Rate for Payer: Networks By Design Commercial |
$0.89
|
| Rate for Payer: Prime Health Services Commercial |
$1.16
|
| Rate for Payer: Riverside University Health System MISP |
$0.55
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.82
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.82
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.69
|
| Rate for Payer: United Healthcare All Other HMO |
$0.69
|
| Rate for Payer: United Healthcare HMO Rider |
$0.69
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.69
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.16
|
| Rate for Payer: Vantage Medical Group Senior |
$1.16
|
|
|
POLYETHYLENE GLYCOL 3350 4.25 GRAM ORAL POWDER PACKET [232762]
|
Facility
|
IP
|
$1.37
|
|
|
Service Code
|
NDC 17856-0962-2
|
| Hospital Charge Code |
ERX232762
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$1.23 |
| Rate for Payer: Blue Shield of California Commercial |
$1.03
|
| Rate for Payer: Blue Shield of California EPN |
$0.73
|
| Rate for Payer: Cash Price |
$0.62
|
| Rate for Payer: Central Health Plan Commercial |
$1.10
|
| Rate for Payer: Cigna of CA HMO |
$0.96
|
| Rate for Payer: Cigna of CA PPO |
$0.96
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.55
|
| Rate for Payer: Galaxy Health WC |
$1.16
|
| Rate for Payer: Global Benefits Group Commercial |
$0.82
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.23
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.27
|
| Rate for Payer: Multiplan Commercial |
$1.03
|
| Rate for Payer: Networks By Design Commercial |
$0.89
|
| Rate for Payer: Prime Health Services Commercial |
$1.16
|
|
|
POLYETHYLENE GLYCOL 400 1 % EYE DROPS [232731]
|
Facility
|
OP
|
$0.42
|
|
|
Service Code
|
NDC 7430001067
|
| Hospital Charge Code |
NDG232731
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.38 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.26
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.36
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.23
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.23
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.25
|
| Rate for Payer: Blue Distinction Transplant |
$0.25
|
| Rate for Payer: Blue Shield of California Commercial |
$0.26
|
| Rate for Payer: Blue Shield of California EPN |
$0.21
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Central Health Plan Commercial |
$0.34
|
| Rate for Payer: Cigna of CA HMO |
$0.29
|
| Rate for Payer: Cigna of CA PPO |
$0.29
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.36
|
| Rate for Payer: Dignity Health Media |
$0.36
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.17
|
| Rate for Payer: Galaxy Health WC |
$0.36
|
| Rate for Payer: Global Benefits Group Commercial |
$0.25
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.38
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.32
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.32
|
| Rate for Payer: Networks By Design Commercial |
$0.27
|
| Rate for Payer: Prime Health Services Commercial |
$0.36
|
| Rate for Payer: Riverside University Health System MISP |
$0.17
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.25
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.25
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.21
|
| Rate for Payer: United Healthcare All Other HMO |
$0.21
|
| Rate for Payer: United Healthcare HMO Rider |
$0.21
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.36
|
| Rate for Payer: Vantage Medical Group Senior |
$0.36
|
|
|
POLYETHYLENE GLYCOL 400 1 % EYE DROPS [232731]
|
Facility
|
IP
|
$0.42
|
|
|
Service Code
|
NDC 7430001067
|
| Hospital Charge Code |
NDG232731
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.38 |
| Rate for Payer: Blue Shield of California Commercial |
$0.32
|
| Rate for Payer: Blue Shield of California EPN |
$0.22
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Central Health Plan Commercial |
$0.34
|
| Rate for Payer: Cigna of CA HMO |
$0.29
|
| Rate for Payer: Cigna of CA PPO |
$0.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: Galaxy Health WC |
$0.36
|
| Rate for Payer: Global Benefits Group Commercial |
$0.25
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.38
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.32
|
| Rate for Payer: Networks By Design Commercial |
$0.27
|
| Rate for Payer: Prime Health Services Commercial |
$0.36
|
|
|
POLYMYXIN B SULFATE 10,000 UNIT-TRIMETHOPRIM 1 MG/ML EYE DROPS [111465]
|
Facility
|
OP
|
$1.31
|
|
|
Service Code
|
NDC 60758-908-10
|
| Hospital Charge Code |
1740272
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$1.18 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.80
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.11
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.72
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.72
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.63
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.77
|
| Rate for Payer: Blue Distinction Transplant |
$0.79
|
| Rate for Payer: Blue Shield of California Commercial |
$0.82
|
| Rate for Payer: Blue Shield of California EPN |
$0.64
|
| Rate for Payer: Cash Price |
$0.59
|
| Rate for Payer: Central Health Plan Commercial |
$1.05
|
| Rate for Payer: Cigna of CA HMO |
$0.92
|
| Rate for Payer: Cigna of CA PPO |
$0.92
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.11
|
| Rate for Payer: Dignity Health Media |
$1.11
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.52
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.52
|
| Rate for Payer: Galaxy Health WC |
$1.11
|
| Rate for Payer: Global Benefits Group Commercial |
$0.79
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.18
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.98
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$0.46
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.26
|
| Rate for Payer: Multiplan Commercial |
$0.98
|
| Rate for Payer: Networks By Design Commercial |
$0.85
|
| Rate for Payer: Prime Health Services Commercial |
$1.11
|
| Rate for Payer: Riverside University Health System MISP |
$0.52
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.79
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.79
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.66
|
| Rate for Payer: United Healthcare All Other HMO |
$0.66
|
| Rate for Payer: United Healthcare HMO Rider |
$0.66
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.66
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.11
|
| Rate for Payer: Vantage Medical Group Senior |
$1.11
|
|
|
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 |
1740272
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$1.12 |
| 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 |
$0.68
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.60
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.73
|
| Rate for Payer: Blue Distinction Transplant |
$0.74
|
| Rate for Payer: Blue Shield of California Commercial |
$0.78
|
| Rate for Payer: Blue Shield of California EPN |
$0.61
|
| Rate for Payer: Cash Price |
$0.56
|
| Rate for Payer: Central Health Plan Commercial |
$0.99
|
| Rate for Payer: Cigna of CA HMO |
$0.87
|
| Rate for Payer: Cigna of CA PPO |
$0.87
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.05
|
| Rate for Payer: Dignity Health Media |
$1.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.50
|
| Rate for Payer: EPIC Health Plan Transplant |
$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: Health Plan of Nevada (Sierra) Other |
$0.93
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$0.43
|
| 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: 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
|
| 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 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
|
$9.58
|
|
|
Service Code
|
NDC 0023-7824-10
|
| Hospital Charge Code |
1740272
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.92 |
| Max. Negotiated Rate |
$8.62 |
| Rate for Payer: Blue Shield of California Commercial |
$7.18
|
| Rate for Payer: Blue Shield of California EPN |
$5.12
|
| Rate for Payer: Cash Price |
$4.31
|
| Rate for Payer: Central Health Plan Commercial |
$7.66
|
| Rate for Payer: Cigna of CA HMO |
$6.71
|
| Rate for Payer: Cigna of CA PPO |
$6.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.83
|
| Rate for Payer: Galaxy Health WC |
$8.14
|
| Rate for Payer: Global Benefits Group Commercial |
$5.75
|
| Rate for Payer: Health Management Network EPO/PPO |
$8.62
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$6.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.92
|
| Rate for Payer: Multiplan Commercial |
$7.18
|
| Rate for Payer: Networks By Design Commercial |
$6.23
|
| Rate for Payer: Prime Health Services Commercial |
$8.14
|
|
|
POLYMYXIN B SULFATE 10,000 UNIT-TRIMETHOPRIM 1 MG/ML EYE DROPS [111465]
|
Facility
|
OP
|
$9.58
|
|
|
Service Code
|
NDC 0023-7824-10
|
| Hospital Charge Code |
1740272
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.92 |
| Max. Negotiated Rate |
$8.62 |
| Rate for Payer: Aetna of CA HMO/PPO |
$5.82
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$8.14
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5.27
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.27
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$4.64
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5.66
|
| Rate for Payer: Blue Distinction Transplant |
$5.75
|
| Rate for Payer: Blue Shield of California Commercial |
$6.03
|
| Rate for Payer: Blue Shield of California EPN |
$4.68
|
| Rate for Payer: Cash Price |
$4.31
|
| Rate for Payer: Central Health Plan Commercial |
$7.66
|
| Rate for Payer: Cigna of CA HMO |
$6.71
|
| Rate for Payer: Cigna of CA PPO |
$6.71
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$8.14
|
| Rate for Payer: Dignity Health Media |
$8.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$8.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.83
|
| Rate for Payer: EPIC Health Plan Transplant |
$3.83
|
| Rate for Payer: Galaxy Health WC |
$8.14
|
| Rate for Payer: Global Benefits Group Commercial |
$5.75
|
| Rate for Payer: Health Management Network EPO/PPO |
$8.62
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$7.18
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$3.35
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$6.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.92
|
| Rate for Payer: Multiplan Commercial |
$7.18
|
| Rate for Payer: Networks By Design Commercial |
$6.23
|
| Rate for Payer: Prime Health Services Commercial |
$8.14
|
| Rate for Payer: Riverside University Health System MISP |
$3.83
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$5.75
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$5.75
|
| Rate for Payer: United Healthcare All Other Commercial |
$4.79
|
| Rate for Payer: United Healthcare All Other HMO |
$4.79
|
| Rate for Payer: United Healthcare HMO Rider |
$4.79
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4.79
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8.14
|
| Rate for Payer: Vantage Medical Group Senior |
$8.14
|
|
|
POLYMYXIN B SULFATE 10,000 UNIT-TRIMETHOPRIM 1 MG/ML EYE DROPS [111465]
|
Facility
|
IP
|
$1.31
|
|
|
Service Code
|
NDC 60758-908-10
|
| Hospital Charge Code |
1740272
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$1.18 |
| Rate for Payer: Blue Shield of California Commercial |
$0.98
|
| Rate for Payer: Blue Shield of California EPN |
$0.70
|
| Rate for Payer: Cash Price |
$0.59
|
| Rate for Payer: Central Health Plan Commercial |
$1.05
|
| Rate for Payer: Cigna of CA HMO |
$0.92
|
| Rate for Payer: Cigna of CA PPO |
$0.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.52
|
| Rate for Payer: Galaxy Health WC |
$1.11
|
| Rate for Payer: Global Benefits Group Commercial |
$0.79
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.18
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.26
|
| Rate for Payer: Multiplan Commercial |
$0.98
|
| Rate for Payer: Networks By Design Commercial |
$0.85
|
| Rate for Payer: Prime Health Services Commercial |
$1.11
|
|
|
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 |
1740272
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$1.12 |
| Rate for Payer: Blue Shield of California Commercial |
$0.93
|
| Rate for Payer: Blue Shield of California EPN |
$0.66
|
| Rate for Payer: Cash Price |
$0.56
|
| Rate for Payer: Central Health Plan Commercial |
$0.99
|
| Rate for Payer: Cigna of CA HMO |
$0.87
|
| Rate for Payer: Cigna of CA PPO |
$0.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$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: LLUH Dept of Risk Management WC |
$0.25
|
| Rate for Payer: Multiplan Commercial |
$0.93
|
| Rate for Payer: Networks By Design Commercial |
$0.81
|
| Rate for Payer: Prime Health Services Commercial |
$1.05
|
|
|
POLYMYXIN B SULFATE 500,000 UNIT SOLUTION FOR INJECTION [6393]
|
Facility
|
OP
|
$12.00
|
|
|
Service Code
|
NDC 55150-234-10
|
| Hospital Charge Code |
1756008
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.40 |
| Max. Negotiated Rate |
$10.80 |
| 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 |
$6.60
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$5.81
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7.09
|
| Rate for Payer: Blue Distinction Transplant |
$7.20
|
| Rate for Payer: Blue Shield of California Commercial |
$7.55
|
| Rate for Payer: Blue Shield of California EPN |
$5.87
|
| Rate for Payer: Cash Price |
$5.40
|
| 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 Media |
$10.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$10.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.80
|
| Rate for Payer: EPIC Health Plan Transplant |
$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: Health Plan of Nevada (Sierra) Other |
$9.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$4.20
|
| 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: 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
|
| 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 Medi-Cal |
$10.20
|
| Rate for Payer: Vantage Medical Group Senior |
$10.20
|
|
|
POLYMYXIN B SULFATE 500,000 UNIT SOLUTION FOR INJECTION [6393]
|
Facility
|
IP
|
$12.00
|
|
|
Service Code
|
NDC 55150-234-10
|
| Hospital Charge Code |
1756008
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.40 |
| Max. Negotiated Rate |
$10.80 |
| Rate for Payer: Blue Shield of California Commercial |
$9.00
|
| Rate for Payer: Blue Shield of California EPN |
$6.41
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Central Health Plan Commercial |
$9.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$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: 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
|
|
|
POLYOXYL (100) STEARYL ETHER (BULK) 100 % WAX [192296]
|
Facility
|
IP
|
$1.73
|
|
|
Service Code
|
NDC 5192723020
|
| Hospital Charge Code |
NDG192296
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$1.56 |
| Rate for Payer: Blue Shield of California Commercial |
$1.30
|
| Rate for Payer: Blue Shield of California EPN |
$0.92
|
| Rate for Payer: Cash Price |
$0.78
|
| Rate for Payer: Central Health Plan Commercial |
$1.38
|
| Rate for Payer: Cigna of CA HMO |
$1.21
|
| Rate for Payer: Cigna of CA PPO |
$1.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$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: 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 |
NDG192296
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$1.56 |
| 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 |
$0.95
|
| 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 Distinction Transplant |
$1.04
|
| Rate for Payer: Blue Shield of California Commercial |
$1.09
|
| Rate for Payer: Blue Shield of California EPN |
$0.85
|
| Rate for Payer: Cash Price |
$0.78
|
| Rate for Payer: Central Health Plan Commercial |
$1.38
|
| Rate for Payer: Cigna of CA HMO |
$1.21
|
| Rate for Payer: Cigna of CA PPO |
$1.21
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.47
|
| Rate for Payer: Dignity Health Media |
$1.47
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.69
|
| Rate for Payer: EPIC Health Plan Transplant |
$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: Health Plan of Nevada (Sierra) Other |
$1.30
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$0.61
|
| 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: 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
|
| 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 Medi-Cal |
$1.47
|
| Rate for Payer: Vantage Medical Group Senior |
$1.47
|
|
|
POLYVINYL ALCOHOL 1.4 % EYE DROPS [27994]
|
Facility
|
IP
|
$0.47
|
|
|
Service Code
|
NDC 17478-060-12
|
| Hospital Charge Code |
1740338
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.42 |
| Rate for Payer: Blue Shield of California Commercial |
$0.35
|
| Rate for Payer: Blue Shield of California EPN |
$0.25
|
| Rate for Payer: Cash Price |
$0.21
|
| Rate for Payer: Central Health Plan Commercial |
$0.38
|
| Rate for Payer: Cigna of CA HMO |
$0.33
|
| Rate for Payer: Cigna of CA PPO |
$0.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| Rate for Payer: Galaxy Health WC |
$0.40
|
| Rate for Payer: Global Benefits Group Commercial |
$0.28
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.42
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.35
|
| Rate for Payer: Networks By Design Commercial |
$0.31
|
| Rate for Payer: Prime Health Services Commercial |
$0.40
|
|
|
POLYVINYL ALCOHOL 1.4 % EYE DROPS [27994]
|
Facility
|
OP
|
$0.47
|
|
|
Service Code
|
NDC 17478-060-12
|
| Hospital Charge Code |
1740338
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.42 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.29
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.40
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.26
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.26
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.23
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.28
|
| Rate for Payer: Blue Distinction Transplant |
$0.28
|
| Rate for Payer: Blue Shield of California Commercial |
$0.30
|
| Rate for Payer: Blue Shield of California EPN |
$0.23
|
| Rate for Payer: Cash Price |
$0.21
|
| Rate for Payer: Central Health Plan Commercial |
$0.38
|
| Rate for Payer: Cigna of CA HMO |
$0.33
|
| Rate for Payer: Cigna of CA PPO |
$0.33
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.40
|
| Rate for Payer: Dignity Health Media |
$0.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.19
|
| Rate for Payer: Galaxy Health WC |
$0.40
|
| Rate for Payer: Global Benefits Group Commercial |
$0.28
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.42
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.35
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.35
|
| Rate for Payer: Networks By Design Commercial |
$0.31
|
| Rate for Payer: Prime Health Services Commercial |
$0.40
|
| Rate for Payer: Riverside University Health System MISP |
$0.19
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.28
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.28
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.24
|
| Rate for Payer: United Healthcare All Other HMO |
$0.24
|
| Rate for Payer: United Healthcare HMO Rider |
$0.24
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.24
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.40
|
| Rate for Payer: Vantage Medical Group Senior |
$0.40
|
|
|
PORACTANT ALFA 120 MG/1.5 ML INTRATRACHEAL SUSPENSION [27047]
|
Facility
|
OP
|
$435.45
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
1720928
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$87.09 |
| Max. Negotiated Rate |
$391.90 |
| Rate for Payer: Aetna of CA HMO/PPO |
$264.45
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$370.13
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$239.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$239.50
|
| Rate for Payer: Blue Distinction Transplant |
$261.27
|
| Rate for Payer: Blue Shield of California Commercial |
$273.90
|
| Rate for Payer: Blue Shield of California EPN |
$212.94
|
| Rate for Payer: Cash Price |
$195.95
|
| Rate for Payer: Central Health Plan Commercial |
$348.36
|
| Rate for Payer: Cigna of CA HMO |
$304.82
|
| Rate for Payer: Cigna of CA PPO |
$304.82
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$370.13
|
| Rate for Payer: Dignity Health Media |
$370.13
|
| Rate for Payer: Dignity Health Medi-Cal |
$370.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$174.18
|
| Rate for Payer: EPIC Health Plan Transplant |
$174.18
|
| Rate for Payer: Galaxy Health WC |
$370.13
|
| Rate for Payer: Global Benefits Group Commercial |
$261.27
|
| Rate for Payer: Health Management Network EPO/PPO |
$391.90
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$326.59
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$152.41
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$290.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$87.09
|
| Rate for Payer: Multiplan Commercial |
$326.59
|
| Rate for Payer: Networks By Design Commercial |
$217.72
|
| Rate for Payer: Prime Health Services Commercial |
$370.13
|
| Rate for Payer: Riverside University Health System MISP |
$174.18
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$261.27
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$261.27
|
| Rate for Payer: United Healthcare All Other Commercial |
$217.72
|
| Rate for Payer: United Healthcare All Other HMO |
$217.72
|
| Rate for Payer: United Healthcare HMO Rider |
$217.72
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$217.72
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$370.13
|
| Rate for Payer: Vantage Medical Group Senior |
$370.13
|
|
|
PORACTANT ALFA 120 MG/1.5 ML INTRATRACHEAL SUSPENSION [27047]
|
Facility
|
IP
|
$435.45
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
1720928
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$87.09 |
| Max. Negotiated Rate |
$391.90 |
| Rate for Payer: Blue Shield of California Commercial |
$326.59
|
| Rate for Payer: Blue Shield of California EPN |
$232.53
|
| Rate for Payer: Cash Price |
$195.95
|
| Rate for Payer: Central Health Plan Commercial |
$348.36
|
| Rate for Payer: Cigna of CA HMO |
$304.82
|
| Rate for Payer: Cigna of CA PPO |
$304.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$174.18
|
| Rate for Payer: EPIC Health Plan Transplant |
$174.18
|
| Rate for Payer: Galaxy Health WC |
$370.13
|
| Rate for Payer: Global Benefits Group Commercial |
$261.27
|
| Rate for Payer: Health Management Network EPO/PPO |
$391.90
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$290.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$165.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$87.09
|
| Rate for Payer: Multiplan Commercial |
$326.59
|
| Rate for Payer: Networks By Design Commercial |
$217.72
|
| Rate for Payer: Prime Health Services Commercial |
$370.13
|
| Rate for Payer: United Healthcare All Other Commercial |
$164.43
|
| Rate for Payer: United Healthcare All Other HMO |
$160.59
|
| Rate for Payer: United Healthcare HMO Rider |
$157.11
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$143.70
|
|
|
PORACTANT ALFA 240 MG/3 ML INTRATRACHEAL SUSPENSION [117872]
|
Facility
|
IP
|
$429.33
|
|
|
Service Code
|
NDC 10122-510-03
|
| Hospital Charge Code |
1720929
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$85.87 |
| Max. Negotiated Rate |
$386.40 |
| Rate for Payer: Blue Shield of California Commercial |
$322.00
|
| Rate for Payer: Blue Shield of California EPN |
$229.26
|
| Rate for Payer: Cash Price |
$193.20
|
| Rate for Payer: Central Health Plan Commercial |
$343.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$171.73
|
| Rate for Payer: Galaxy Health WC |
$364.93
|
| Rate for Payer: Global Benefits Group Commercial |
$257.60
|
| Rate for Payer: Health Management Network EPO/PPO |
$386.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$286.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$163.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$85.87
|
| Rate for Payer: Multiplan Commercial |
$322.00
|
| Rate for Payer: Networks By Design Commercial |
$279.06
|
| Rate for Payer: Prime Health Services Commercial |
$364.93
|
|
|
PORACTANT ALFA 240 MG/3 ML INTRATRACHEAL SUSPENSION [117872]
|
Facility
|
OP
|
$429.33
|
|
|
Service Code
|
NDC 10122-510-03
|
| Hospital Charge Code |
1720929
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$85.87 |
| Max. Negotiated Rate |
$386.40 |
| Rate for Payer: Aetna of CA HMO/PPO |
$260.73
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$364.93
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$236.13
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$236.13
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$207.88
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$253.65
|
| Rate for Payer: Blue Distinction Transplant |
$257.60
|
| Rate for Payer: Blue Shield of California Commercial |
$270.05
|
| Rate for Payer: Blue Shield of California EPN |
$209.94
|
| Rate for Payer: Cash Price |
$193.20
|
| Rate for Payer: Central Health Plan Commercial |
$343.46
|
| Rate for Payer: Cigna of CA HMO |
$274.77
|
| Rate for Payer: Cigna of CA PPO |
$317.70
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$364.93
|
| Rate for Payer: Dignity Health Media |
$364.93
|
| Rate for Payer: Dignity Health Medi-Cal |
$364.93
|
| Rate for Payer: EPIC Health Plan Commercial |
$171.73
|
| Rate for Payer: EPIC Health Plan Transplant |
$171.73
|
| Rate for Payer: Galaxy Health WC |
$364.93
|
| Rate for Payer: Global Benefits Group Commercial |
$257.60
|
| Rate for Payer: Health Management Network EPO/PPO |
$386.40
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$322.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$150.27
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$286.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$163.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$85.87
|
| Rate for Payer: Multiplan Commercial |
$322.00
|
| Rate for Payer: Networks By Design Commercial |
$279.06
|
| Rate for Payer: Prime Health Services Commercial |
$364.93
|
| Rate for Payer: Riverside University Health System MISP |
$171.73
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$257.60
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$257.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$214.66
|
| Rate for Payer: United Healthcare All Other HMO |
$214.66
|
| Rate for Payer: United Healthcare HMO Rider |
$214.66
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$214.66
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$364.93
|
| Rate for Payer: Vantage Medical Group Senior |
$364.93
|
|
|
PORFIMER 75 MG INTRAVENOUS SOLUTION [14472]
|
Facility
|
IP
|
$25,980.00
|
|
|
Service Code
|
CPT J9600
|
| Hospital Charge Code |
ERX14472
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5,196.00 |
| Max. Negotiated Rate |
$23,382.00 |
| Rate for Payer: Blue Shield of California Commercial |
$19,485.00
|
| Rate for Payer: Blue Shield of California EPN |
$13,873.32
|
| Rate for Payer: Cash Price |
$11,691.00
|
| Rate for Payer: Central Health Plan Commercial |
$20,784.00
|
| Rate for Payer: Cigna of CA HMO |
$18,186.00
|
| Rate for Payer: Cigna of CA PPO |
$18,186.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$10,392.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$10,392.00
|
| Rate for Payer: Galaxy Health WC |
$22,083.00
|
| Rate for Payer: Global Benefits Group Commercial |
$15,588.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$23,382.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$17,328.66
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9,898.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5,196.00
|
| Rate for Payer: Multiplan Commercial |
$19,485.00
|
| Rate for Payer: Networks By Design Commercial |
$12,990.00
|
| Rate for Payer: Prime Health Services Commercial |
$22,083.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$9,810.05
|
| Rate for Payer: United Healthcare All Other HMO |
$9,581.42
|
| Rate for Payer: United Healthcare HMO Rider |
$9,373.58
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$8,573.40
|
|
|
PORFIMER 75 MG INTRAVENOUS SOLUTION [14472]
|
Facility
|
OP
|
$25,980.00
|
|
|
Service Code
|
CPT J9600
|
| Hospital Charge Code |
ERX14472
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5,190.78 |
| Max. Negotiated Rate |
$136,309.36 |
| Rate for Payer: Adventist Health Medi-Cal |
$22,828.16
|
| Rate for Payer: Aetna of CA HMO/PPO |
$136,309.36
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$28,535.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$25,110.98
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$25,110.98
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$5,190.78
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,683.37
|
| Rate for Payer: Blue Distinction Transplant |
$15,588.00
|
| Rate for Payer: Blue Shield of California Commercial |
$27,772.80
|
| Rate for Payer: Blue Shield of California EPN |
$25,248.00
|
| Rate for Payer: Caremore Medicare Advantage |
$22,828.16
|
| Rate for Payer: Cash Price |
$11,691.00
|
| Rate for Payer: Cash Price |
$11,691.00
|
| Rate for Payer: Central Health Plan Commercial |
$20,784.00
|
| Rate for Payer: Cigna of CA HMO |
$18,186.00
|
| Rate for Payer: Cigna of CA PPO |
$18,186.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$34,242.24
|
| Rate for Payer: Dignity Health Media |
$22,828.16
|
| Rate for Payer: Dignity Health Medi-Cal |
$25,110.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$30,818.02
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$22,828.16
|
| Rate for Payer: EPIC Health Plan Transplant |
$22,828.16
|
| Rate for Payer: Galaxy Health WC |
$22,083.00
|
| Rate for Payer: Global Benefits Group Commercial |
$15,588.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$23,382.00
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$19,485.00
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$37,438.18
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$37,666.46
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$22,828.16
|
| Rate for Payer: InnovAge PACE Commercial |
$34,242.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$17,328.66
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9,898.38
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$22,828.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5,196.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$30,589.73
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$30,589.73
|
| Rate for Payer: Multiplan Commercial |
$19,485.00
|
| Rate for Payer: Networks By Design Commercial |
$12,990.00
|
| Rate for Payer: Prime Health Services Commercial |
$22,083.00
|
| Rate for Payer: Prime Health Services Medicare |
$24,197.85
|
| Rate for Payer: Riverside University Health System MISP |
$25,110.98
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$15,588.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$15,588.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$12,990.00
|
| Rate for Payer: United Healthcare All Other HMO |
$12,990.00
|
| Rate for Payer: United Healthcare HMO Rider |
$12,990.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$12,990.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$34,242.24
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$25,110.98
|
| Rate for Payer: Vantage Medical Group Senior |
$22,828.16
|
|
|
POSACONAZOLE 100 MG TABLET,DELAYED RELEASE [204306]
|
Facility
|
IP
|
$9.00
|
|
|
Service Code
|
NDC 70748-258-07
|
| Hospital Charge Code |
ERX204306
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.80 |
| Max. Negotiated Rate |
$8.10 |
| Rate for Payer: Blue Shield of California Commercial |
$6.75
|
| Rate for Payer: Blue Shield of California EPN |
$4.81
|
| Rate for Payer: Cash Price |
$4.05
|
| Rate for Payer: Central Health Plan Commercial |
$7.20
|
| Rate for Payer: Cigna of CA HMO |
$6.30
|
| Rate for Payer: Cigna of CA PPO |
$6.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$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: 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
|
|
