|
RIZATRIPTAN 10 MG TABLET [23377]
|
Facility
OP
|
$1.80
|
|
|
Service Code
|
NDC 0093-7472-19
|
| Hospital Charge Code |
1712228
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$1.62 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.09
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.53
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.99
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.99
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.87
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.06
|
| Rate for Payer: BCBS Transplant Transplant |
$1.08
|
| Rate for Payer: Blue Shield of California Commercial |
$1.13
|
| Rate for Payer: Blue Shield of California EPN |
$0.88
|
| Rate for Payer: Cash Price |
$0.81
|
| Rate for Payer: Central Health Plan Commercial |
$1.44
|
| Rate for Payer: Cigna of CA HMO |
$1.26
|
| Rate for Payer: Cigna of CA PPO |
$1.26
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.72
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.72
|
| Rate for Payer: Galaxy Health WC |
$1.53
|
| Rate for Payer: Global Benefits Group Commercial |
$1.08
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.62
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1.35
|
| Rate for Payer: IEHP medi-cal |
$0.63
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.36
|
| Rate for Payer: Multiplan Commercial |
$1.35
|
| Rate for Payer: Networks By Design Commercial |
$1.17
|
| Rate for Payer: Prime Health Services Commercial |
$1.53
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$1.08
|
| Rate for Payer: Riverside University Health MISP |
$0.72
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.08
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.08
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.90
|
| Rate for Payer: United Healthcare All Other HMO |
$0.90
|
| Rate for Payer: United Healthcare HMO Rider |
$0.90
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.90
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.53
|
| Rate for Payer: Vantage Medical Group Senior |
$1.53
|
|
|
RIZATRIPTAN 10 MG TABLET [23377]
|
Facility
OP
|
$1.19
|
|
|
Service Code
|
NDC 57237-088-63
|
| Hospital Charge Code |
1712228
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$1.07 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.72
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.01
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.65
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.65
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.58
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.70
|
| Rate for Payer: BCBS Transplant Transplant |
$0.71
|
| Rate for Payer: Blue Shield of California Commercial |
$0.75
|
| Rate for Payer: Blue Shield of California EPN |
$0.58
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Central Health Plan Commercial |
$0.95
|
| Rate for Payer: Cigna of CA HMO |
$0.83
|
| Rate for Payer: Cigna of CA PPO |
$0.83
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.48
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.48
|
| Rate for Payer: Galaxy Health WC |
$1.01
|
| Rate for Payer: Global Benefits Group Commercial |
$0.71
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.07
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.89
|
| Rate for Payer: IEHP medi-cal |
$0.42
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
| Rate for Payer: Multiplan Commercial |
$0.89
|
| Rate for Payer: Networks By Design Commercial |
$0.77
|
| Rate for Payer: Prime Health Services Commercial |
$1.01
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.71
|
| Rate for Payer: Riverside University Health MISP |
$0.48
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.71
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.71
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.60
|
| Rate for Payer: United Healthcare All Other HMO |
$0.60
|
| Rate for Payer: United Healthcare HMO Rider |
$0.60
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.01
|
| Rate for Payer: Vantage Medical Group Senior |
$1.01
|
|
|
RIZATRIPTAN 10 MG TABLET [23377]
|
Facility
IP
|
$1.80
|
|
|
Service Code
|
NDC 0093-7472-19
|
| Hospital Charge Code |
1712228
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$1.62 |
| Rate for Payer: Blue Shield of California Commercial |
$1.35
|
| Rate for Payer: Blue Shield of California EPN |
$0.96
|
| Rate for Payer: Cash Price |
$0.81
|
| Rate for Payer: Central Health Plan Commercial |
$1.44
|
| Rate for Payer: Cigna of CA HMO |
$1.26
|
| Rate for Payer: Cigna of CA PPO |
$1.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.72
|
| Rate for Payer: Galaxy Health WC |
$1.53
|
| Rate for Payer: Global Benefits Group Commercial |
$1.08
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.62
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.36
|
| Rate for Payer: Multiplan Commercial |
$1.35
|
| Rate for Payer: Networks By Design Commercial |
$1.17
|
| Rate for Payer: Prime Health Services Commercial |
$1.53
|
|
|
RIZATRIPTAN 10 MG TABLET [23377]
|
Facility
IP
|
$1.19
|
|
|
Service Code
|
NDC 57237-088-63
|
| Hospital Charge Code |
1712228
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$1.07 |
| Rate for Payer: Blue Shield of California Commercial |
$0.89
|
| Rate for Payer: Blue Shield of California EPN |
$0.64
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Central Health Plan Commercial |
$0.95
|
| Rate for Payer: Cigna of CA HMO |
$0.83
|
| Rate for Payer: Cigna of CA PPO |
$0.83
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.48
|
| Rate for Payer: Galaxy Health WC |
$1.01
|
| Rate for Payer: Global Benefits Group Commercial |
$0.71
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
| Rate for Payer: Multiplan Commercial |
$0.89
|
| Rate for Payer: Networks By Design Commercial |
$0.77
|
| Rate for Payer: Prime Health Services Commercial |
$1.01
|
|
|
RIZATRIPTAN 5 MG TABLET [23376]
|
Facility
OP
|
$1.44
|
|
|
Service Code
|
NDC 68462-465-99
|
| Hospital Charge Code |
1712622
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$1.30 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.87
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.22
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.79
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.79
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.70
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.85
|
| Rate for Payer: BCBS Transplant Transplant |
$0.86
|
| Rate for Payer: Blue Shield of California Commercial |
$0.91
|
| Rate for Payer: Blue Shield of California EPN |
$0.70
|
| Rate for Payer: Cash Price |
$0.65
|
| Rate for Payer: Central Health Plan Commercial |
$1.15
|
| Rate for Payer: Cigna of CA HMO |
$1.01
|
| Rate for Payer: Cigna of CA PPO |
$1.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.58
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.58
|
| Rate for Payer: Galaxy Health WC |
$1.22
|
| Rate for Payer: Global Benefits Group Commercial |
$0.86
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.30
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1.08
|
| Rate for Payer: IEHP medi-cal |
$0.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Multiplan Commercial |
$1.08
|
| Rate for Payer: Networks By Design Commercial |
$0.94
|
| Rate for Payer: Prime Health Services Commercial |
$1.22
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.86
|
| Rate for Payer: Riverside University Health MISP |
$0.58
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.86
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.86
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.72
|
| Rate for Payer: United Healthcare All Other HMO |
$0.72
|
| Rate for Payer: United Healthcare HMO Rider |
$0.72
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.72
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.22
|
| Rate for Payer: Vantage Medical Group Senior |
$1.22
|
|
|
RIZATRIPTAN 5 MG TABLET [23376]
|
Facility
OP
|
$1.44
|
|
|
Service Code
|
NDC 68462-465-40
|
| Hospital Charge Code |
1712622
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$1.30 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.87
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.22
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.79
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.79
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.70
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.85
|
| Rate for Payer: BCBS Transplant Transplant |
$0.86
|
| Rate for Payer: Blue Shield of California Commercial |
$0.91
|
| Rate for Payer: Blue Shield of California EPN |
$0.70
|
| Rate for Payer: Cash Price |
$0.65
|
| Rate for Payer: Central Health Plan Commercial |
$1.15
|
| Rate for Payer: Cigna of CA HMO |
$1.01
|
| Rate for Payer: Cigna of CA PPO |
$1.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.58
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.58
|
| Rate for Payer: Galaxy Health WC |
$1.22
|
| Rate for Payer: Global Benefits Group Commercial |
$0.86
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.30
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1.08
|
| Rate for Payer: IEHP medi-cal |
$0.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Multiplan Commercial |
$1.08
|
| Rate for Payer: Networks By Design Commercial |
$0.94
|
| Rate for Payer: Prime Health Services Commercial |
$1.22
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.86
|
| Rate for Payer: Riverside University Health MISP |
$0.58
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.86
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.86
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.72
|
| Rate for Payer: United Healthcare All Other HMO |
$0.72
|
| Rate for Payer: United Healthcare HMO Rider |
$0.72
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.72
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.22
|
| Rate for Payer: Vantage Medical Group Senior |
$1.22
|
|
|
RIZATRIPTAN 5 MG TABLET [23376]
|
Facility
IP
|
$1.44
|
|
|
Service Code
|
NDC 68462-465-99
|
| Hospital Charge Code |
1712622
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$1.30 |
| Rate for Payer: Blue Shield of California Commercial |
$1.08
|
| Rate for Payer: Blue Shield of California EPN |
$0.77
|
| Rate for Payer: Cash Price |
$0.65
|
| Rate for Payer: Central Health Plan Commercial |
$1.15
|
| Rate for Payer: Cigna of CA HMO |
$1.01
|
| Rate for Payer: Cigna of CA PPO |
$1.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.58
|
| Rate for Payer: Galaxy Health WC |
$1.22
|
| Rate for Payer: Global Benefits Group Commercial |
$0.86
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Multiplan Commercial |
$1.08
|
| Rate for Payer: Networks By Design Commercial |
$0.94
|
| Rate for Payer: Prime Health Services Commercial |
$1.22
|
|
|
RIZATRIPTAN 5 MG TABLET [23376]
|
Facility
IP
|
$1.44
|
|
|
Service Code
|
NDC 68462-465-40
|
| Hospital Charge Code |
1712622
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$1.30 |
| Rate for Payer: Blue Shield of California Commercial |
$1.08
|
| Rate for Payer: Blue Shield of California EPN |
$0.77
|
| Rate for Payer: Cash Price |
$0.65
|
| Rate for Payer: Central Health Plan Commercial |
$1.15
|
| Rate for Payer: Cigna of CA HMO |
$1.01
|
| Rate for Payer: Cigna of CA PPO |
$1.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.58
|
| Rate for Payer: Galaxy Health WC |
$1.22
|
| Rate for Payer: Global Benefits Group Commercial |
$0.86
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Multiplan Commercial |
$1.08
|
| Rate for Payer: Networks By Design Commercial |
$0.94
|
| Rate for Payer: Prime Health Services Commercial |
$1.22
|
|
|
Robotic Surgery
|
Facility
IP
|
$20,000.00
|
|
|
Service Code
|
ICD 8E0W4CZ
|
| Min. Negotiated Rate |
$20,000.00 |
| Max. Negotiated Rate |
$20,000.00 |
| Rate for Payer: Networks By Design Commercial |
$20,000.00
|
|
|
ROCURONIUM 50 MG/5 ML VIAL- CODE [40895812]
|
Facility
IP
|
$1.16
|
|
|
Service Code
|
NDC 67457-228-05
|
| Hospital Charge Code |
1722005
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$1.04 |
| Rate for Payer: Blue Shield of California Commercial |
$0.87
|
| Rate for Payer: Blue Shield of California EPN |
$0.62
|
| Rate for Payer: Cash Price |
$0.52
|
| Rate for Payer: Central Health Plan Commercial |
$0.93
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.46
|
| Rate for Payer: Galaxy Health WC |
$0.99
|
| Rate for Payer: Global Benefits Group Commercial |
$0.70
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.77
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: Multiplan Commercial |
$0.87
|
| Rate for Payer: Networks By Design Commercial |
$0.75
|
| Rate for Payer: Prime Health Services Commercial |
$0.99
|
|
|
ROCURONIUM 50 MG/5 ML VIAL- CODE [40895812]
|
Facility
OP
|
$1.16
|
|
|
Service Code
|
NDC 67457-228-05
|
| Hospital Charge Code |
1722005
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$1.04 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.70
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.99
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.64
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.64
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.56
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.69
|
| Rate for Payer: BCBS Transplant Transplant |
$0.70
|
| Rate for Payer: Blue Shield of California Commercial |
$0.73
|
| Rate for Payer: Blue Shield of California EPN |
$0.57
|
| Rate for Payer: Cash Price |
$0.52
|
| Rate for Payer: Cash Price |
$0.52
|
| Rate for Payer: Central Health Plan Commercial |
$0.93
|
| Rate for Payer: Cigna of CA HMO |
$0.74
|
| Rate for Payer: Cigna of CA PPO |
$0.86
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.99
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.46
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.46
|
| Rate for Payer: Galaxy Health WC |
$0.99
|
| Rate for Payer: Global Benefits Group Commercial |
$0.70
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.04
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.87
|
| Rate for Payer: IEHP medi-cal |
$0.41
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.77
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: Multiplan Commercial |
$0.87
|
| Rate for Payer: Networks By Design Commercial |
$0.75
|
| Rate for Payer: Prime Health Services Commercial |
$0.99
|
| Rate for Payer: Riverside University Health MISP |
$0.46
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.70
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.70
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.58
|
| Rate for Payer: United Healthcare All Other HMO |
$0.58
|
| Rate for Payer: United Healthcare HMO Rider |
$0.58
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.58
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.99
|
| Rate for Payer: Vantage Medical Group Senior |
$0.99
|
|
|
ROFLUMILAST 500 MCG TABLET [109401]
|
Facility
IP
|
$17.24
|
|
|
Service Code
|
NDC 0310-0095-30
|
| Hospital Charge Code |
ERX109401
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.45 |
| Max. Negotiated Rate |
$15.52 |
| Rate for Payer: Blue Shield of California Commercial |
$12.93
|
| Rate for Payer: Blue Shield of California EPN |
$9.21
|
| Rate for Payer: Cash Price |
$7.76
|
| Rate for Payer: Central Health Plan Commercial |
$13.79
|
| Rate for Payer: Cigna of CA HMO |
$12.07
|
| Rate for Payer: Cigna of CA PPO |
$12.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.90
|
| Rate for Payer: Galaxy Health WC |
$14.65
|
| Rate for Payer: Global Benefits Group Commercial |
$10.34
|
| Rate for Payer: Health Management Network EPO/PPO |
$15.52
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$11.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.45
|
| Rate for Payer: Multiplan Commercial |
$12.93
|
| Rate for Payer: Networks By Design Commercial |
$11.21
|
| Rate for Payer: Prime Health Services Commercial |
$14.65
|
|
|
ROFLUMILAST 500 MCG TABLET [109401]
|
Facility
IP
|
$0.72
|
|
|
Service Code
|
NDC 72205-200-30
|
| Hospital Charge Code |
ERX109401
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.65 |
| Rate for Payer: Blue Shield of California Commercial |
$0.54
|
| Rate for Payer: Blue Shield of California EPN |
$0.38
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Central Health Plan Commercial |
$0.58
|
| Rate for Payer: Cigna of CA HMO |
$0.50
|
| Rate for Payer: Cigna of CA PPO |
$0.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.29
|
| Rate for Payer: Galaxy Health WC |
$0.61
|
| Rate for Payer: Global Benefits Group Commercial |
$0.43
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.65
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.54
|
| Rate for Payer: Networks By Design Commercial |
$0.47
|
| Rate for Payer: Prime Health Services Commercial |
$0.61
|
|
|
ROFLUMILAST 500 MCG TABLET [109401]
|
Facility
OP
|
$17.24
|
|
|
Service Code
|
NDC 0310-0095-30
|
| Hospital Charge Code |
ERX109401
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.45 |
| Max. Negotiated Rate |
$15.52 |
| Rate for Payer: Aetna of CA HMO/PPO |
$10.47
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$14.65
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$9.48
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$9.48
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$8.35
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$10.19
|
| Rate for Payer: BCBS Transplant Transplant |
$10.34
|
| Rate for Payer: Blue Shield of California Commercial |
$10.84
|
| Rate for Payer: Blue Shield of California EPN |
$8.43
|
| Rate for Payer: Cash Price |
$7.76
|
| Rate for Payer: Central Health Plan Commercial |
$13.79
|
| Rate for Payer: Cigna of CA HMO |
$12.07
|
| Rate for Payer: Cigna of CA PPO |
$12.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$14.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.90
|
| Rate for Payer: EPIC Health Plan Transplant |
$6.90
|
| Rate for Payer: Galaxy Health WC |
$14.65
|
| Rate for Payer: Global Benefits Group Commercial |
$10.34
|
| Rate for Payer: Health Management Network EPO/PPO |
$15.52
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$12.93
|
| Rate for Payer: IEHP medi-cal |
$6.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$11.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.45
|
| Rate for Payer: Multiplan Commercial |
$12.93
|
| Rate for Payer: Networks By Design Commercial |
$11.21
|
| Rate for Payer: Prime Health Services Commercial |
$14.65
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$10.34
|
| Rate for Payer: Riverside University Health MISP |
$6.90
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$10.34
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$10.34
|
| Rate for Payer: United Healthcare All Other Commercial |
$8.62
|
| Rate for Payer: United Healthcare All Other HMO |
$8.62
|
| Rate for Payer: United Healthcare HMO Rider |
$8.62
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$8.62
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$14.65
|
| Rate for Payer: Vantage Medical Group Senior |
$14.65
|
|
|
ROFLUMILAST 500 MCG TABLET [109401]
|
Facility
OP
|
$0.72
|
|
|
Service Code
|
NDC 72205-200-30
|
| Hospital Charge Code |
ERX109401
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.65 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.44
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.61
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.40
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.40
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.35
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.43
|
| Rate for Payer: BCBS Transplant Transplant |
$0.43
|
| Rate for Payer: Blue Shield of California Commercial |
$0.45
|
| Rate for Payer: Blue Shield of California EPN |
$0.35
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Central Health Plan Commercial |
$0.58
|
| Rate for Payer: Cigna of CA HMO |
$0.50
|
| Rate for Payer: Cigna of CA PPO |
$0.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.29
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.29
|
| Rate for Payer: Galaxy Health WC |
$0.61
|
| Rate for Payer: Global Benefits Group Commercial |
$0.43
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.65
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.54
|
| Rate for Payer: IEHP medi-cal |
$0.25
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.54
|
| Rate for Payer: Networks By Design Commercial |
$0.47
|
| Rate for Payer: Prime Health Services Commercial |
$0.61
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.43
|
| Rate for Payer: Riverside University Health MISP |
$0.29
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.43
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.43
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.36
|
| Rate for Payer: United Healthcare All Other HMO |
$0.36
|
| Rate for Payer: United Healthcare HMO Rider |
$0.36
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.36
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.61
|
| Rate for Payer: Vantage Medical Group Senior |
$0.61
|
|
|
ROMIDEPSIN 10 MG/2 ML INTRAVENOUS POWDER FOR SOLUTION [100344]
|
Facility
OP
|
$3,838.38
|
|
|
Service Code
|
CPT J9319
|
| Hospital Charge Code |
ERX100344
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$31.96 |
| Max. Negotiated Rate |
$3,454.54 |
| Rate for Payer: Adventist Health Medi-Cal |
$31.96
|
| Rate for Payer: Aetna of CA HMO/PPO |
$198.06
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$39.95
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$35.16
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$35.16
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$63.24
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$69.24
|
| Rate for Payer: BCBS Transplant Transplant |
$2,303.03
|
| Rate for Payer: Blue Shield of California Commercial |
$2,414.34
|
| Rate for Payer: Blue Shield of California EPN |
$1,876.97
|
| Rate for Payer: Caremore Medicare Advantage |
$31.96
|
| Rate for Payer: Cash Price |
$1,727.27
|
| Rate for Payer: Cash Price |
$1,727.27
|
| Rate for Payer: Central Health Plan Commercial |
$3,070.70
|
| Rate for Payer: Cigna of CA HMO |
$2,686.87
|
| Rate for Payer: Cigna of CA PPO |
$2,686.87
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$47.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$43.15
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$31.96
|
| Rate for Payer: EPIC Health Plan Transplant |
$31.96
|
| Rate for Payer: Galaxy Health WC |
$3,262.62
|
| Rate for Payer: Global Benefits Group Commercial |
$2,303.03
|
| Rate for Payer: Health Management Network EPO/PPO |
$3,454.54
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$2,878.78
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$52.42
|
| Rate for Payer: IEHP medi-cal |
$52.74
|
| Rate for Payer: IEHP Medicare Advantage |
$31.96
|
| Rate for Payer: Innovage PACE Commercial |
$47.94
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2,560.20
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$31.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$767.68
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$42.83
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$42.83
|
| Rate for Payer: Multiplan Commercial |
$2,878.78
|
| Rate for Payer: Networks By Design Commercial |
$1,919.19
|
| Rate for Payer: Prime Health Services Commercial |
$3,262.62
|
| Rate for Payer: Prime Health Services Medicare |
$33.88
|
| Rate for Payer: Riverside University Health MISP |
$35.16
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2,303.03
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2,303.03
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,919.19
|
| Rate for Payer: United Healthcare All Other HMO |
$1,919.19
|
| Rate for Payer: United Healthcare HMO Rider |
$1,919.19
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,919.19
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$47.94
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$35.16
|
| Rate for Payer: Vantage Medical Group Senior |
$31.96
|
|
|
ROMIDEPSIN 10 MG/2 ML INTRAVENOUS POWDER FOR SOLUTION [100344]
|
Facility
IP
|
$3,838.38
|
|
|
Service Code
|
CPT J9319
|
| Hospital Charge Code |
ERX100344
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$767.68 |
| Max. Negotiated Rate |
$3,454.54 |
| Rate for Payer: Blue Shield of California Commercial |
$2,878.78
|
| Rate for Payer: Blue Shield of California EPN |
$2,049.69
|
| Rate for Payer: Cash Price |
$1,727.27
|
| Rate for Payer: Central Health Plan Commercial |
$3,070.70
|
| Rate for Payer: Cigna of CA HMO |
$2,686.87
|
| Rate for Payer: Cigna of CA PPO |
$2,686.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,535.35
|
| Rate for Payer: EPIC Health Plan Transplant |
$1,535.35
|
| Rate for Payer: Galaxy Health WC |
$3,262.62
|
| Rate for Payer: Global Benefits Group Commercial |
$2,303.03
|
| Rate for Payer: Health Management Network EPO/PPO |
$3,454.54
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2,560.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$767.68
|
| Rate for Payer: Multiplan Commercial |
$2,878.78
|
| Rate for Payer: Networks By Design Commercial |
$1,919.19
|
| Rate for Payer: Prime Health Services Commercial |
$3,262.62
|
|
|
ROMIPLOSTIM 125 MCG SUBCUTANEOUS SOLUTION [226462]
|
Facility
OP
|
$1,431.00
|
|
|
Service Code
|
CPT J2796
|
| Hospital Charge Code |
ERX226462
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$85.82 |
| Max. Negotiated Rate |
$1,287.90 |
| Rate for Payer: Adventist Health Medi-Cal |
$96.03
|
| Rate for Payer: Aetna of CA HMO/PPO |
$595.10
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$120.03
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$105.63
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$105.63
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$85.82
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$93.96
|
| Rate for Payer: BCBS Transplant Transplant |
$858.60
|
| Rate for Payer: Blue Shield of California Commercial |
$102.94
|
| Rate for Payer: Blue Shield of California EPN |
$93.58
|
| Rate for Payer: Caremore Medicare Advantage |
$96.03
|
| Rate for Payer: Cash Price |
$643.95
|
| Rate for Payer: Cash Price |
$643.95
|
| Rate for Payer: Central Health Plan Commercial |
$1,144.80
|
| Rate for Payer: Cigna of CA HMO |
$1,001.70
|
| Rate for Payer: Cigna of CA PPO |
$1,001.70
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$144.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$129.64
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$96.03
|
| Rate for Payer: EPIC Health Plan Transplant |
$96.03
|
| Rate for Payer: Galaxy Health WC |
$1,216.35
|
| Rate for Payer: Global Benefits Group Commercial |
$858.60
|
| Rate for Payer: Health Management Network EPO/PPO |
$1,287.90
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1,073.25
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$157.48
|
| Rate for Payer: IEHP medi-cal |
$158.44
|
| Rate for Payer: IEHP Medicare Advantage |
$96.03
|
| Rate for Payer: Innovage PACE Commercial |
$144.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$954.48
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$96.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$286.20
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$128.68
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$128.68
|
| Rate for Payer: Multiplan Commercial |
$1,073.25
|
| Rate for Payer: Networks By Design Commercial |
$715.50
|
| Rate for Payer: Prime Health Services Commercial |
$1,216.35
|
| Rate for Payer: Prime Health Services Medicare |
$101.79
|
| Rate for Payer: Riverside University Health MISP |
$105.63
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$858.60
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$858.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$715.50
|
| Rate for Payer: United Healthcare All Other HMO |
$715.50
|
| Rate for Payer: United Healthcare HMO Rider |
$715.50
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$715.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$144.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$105.63
|
| Rate for Payer: Vantage Medical Group Senior |
$96.03
|
|
|
ROMIPLOSTIM 125 MCG SUBCUTANEOUS SOLUTION [226462]
|
Facility
IP
|
$1,431.00
|
|
|
Service Code
|
CPT J2796
|
| Hospital Charge Code |
ERX226462
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$286.20 |
| Max. Negotiated Rate |
$1,287.90 |
| Rate for Payer: Blue Shield of California Commercial |
$1,073.25
|
| Rate for Payer: Blue Shield of California EPN |
$764.15
|
| Rate for Payer: Cash Price |
$643.95
|
| Rate for Payer: Central Health Plan Commercial |
$1,144.80
|
| Rate for Payer: Cigna of CA HMO |
$1,001.70
|
| Rate for Payer: Cigna of CA PPO |
$1,001.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$572.40
|
| Rate for Payer: EPIC Health Plan Transplant |
$572.40
|
| Rate for Payer: Galaxy Health WC |
$1,216.35
|
| Rate for Payer: Global Benefits Group Commercial |
$858.60
|
| Rate for Payer: Health Management Network EPO/PPO |
$1,287.90
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$954.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$286.20
|
| Rate for Payer: Multiplan Commercial |
$1,073.25
|
| Rate for Payer: Networks By Design Commercial |
$715.50
|
| Rate for Payer: Prime Health Services Commercial |
$1,216.35
|
|
|
ROMIPLOSTIM 250 MCG SUBCUTANEOUS SOLUTION [93566]
|
Facility
OP
|
$2,861.96
|
|
|
Service Code
|
CPT J2796
|
| Hospital Charge Code |
1721175
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$85.82 |
| Max. Negotiated Rate |
$2,575.76 |
| Rate for Payer: Adventist Health Medi-Cal |
$96.03
|
| Rate for Payer: Aetna of CA HMO/PPO |
$595.10
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$120.03
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$105.63
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$105.63
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$85.82
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$93.96
|
| Rate for Payer: BCBS Transplant Transplant |
$1,717.18
|
| Rate for Payer: Blue Shield of California Commercial |
$102.94
|
| Rate for Payer: Blue Shield of California EPN |
$93.58
|
| Rate for Payer: Caremore Medicare Advantage |
$96.03
|
| Rate for Payer: Cash Price |
$1,287.88
|
| Rate for Payer: Cash Price |
$1,287.88
|
| Rate for Payer: Central Health Plan Commercial |
$2,289.57
|
| Rate for Payer: Cigna of CA HMO |
$2,003.37
|
| Rate for Payer: Cigna of CA PPO |
$2,003.37
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$144.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$129.64
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$96.03
|
| Rate for Payer: EPIC Health Plan Transplant |
$96.03
|
| Rate for Payer: Galaxy Health WC |
$2,432.67
|
| Rate for Payer: Global Benefits Group Commercial |
$1,717.18
|
| Rate for Payer: Health Management Network EPO/PPO |
$2,575.76
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$2,146.47
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$157.48
|
| Rate for Payer: IEHP medi-cal |
$158.44
|
| Rate for Payer: IEHP Medicare Advantage |
$96.03
|
| Rate for Payer: Innovage PACE Commercial |
$144.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,908.93
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$96.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$572.39
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$128.68
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$128.68
|
| Rate for Payer: Multiplan Commercial |
$2,146.47
|
| Rate for Payer: Networks By Design Commercial |
$1,430.98
|
| Rate for Payer: Prime Health Services Commercial |
$2,432.67
|
| Rate for Payer: Prime Health Services Medicare |
$101.79
|
| Rate for Payer: Riverside University Health MISP |
$105.63
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1,717.18
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1,717.18
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,430.98
|
| Rate for Payer: United Healthcare All Other HMO |
$1,430.98
|
| Rate for Payer: United Healthcare HMO Rider |
$1,430.98
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,430.98
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$144.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$105.63
|
| Rate for Payer: Vantage Medical Group Senior |
$96.03
|
|
|
ROMIPLOSTIM 250 MCG SUBCUTANEOUS SOLUTION [93566]
|
Facility
IP
|
$2,861.96
|
|
|
Service Code
|
CPT J2796
|
| Hospital Charge Code |
1721175
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$572.39 |
| Max. Negotiated Rate |
$2,575.76 |
| Rate for Payer: Blue Shield of California Commercial |
$2,146.47
|
| Rate for Payer: Blue Shield of California EPN |
$1,528.29
|
| Rate for Payer: Cash Price |
$1,287.88
|
| Rate for Payer: Central Health Plan Commercial |
$2,289.57
|
| Rate for Payer: Cigna of CA HMO |
$2,003.37
|
| Rate for Payer: Cigna of CA PPO |
$2,003.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,144.78
|
| Rate for Payer: EPIC Health Plan Transplant |
$1,144.78
|
| Rate for Payer: Galaxy Health WC |
$2,432.67
|
| Rate for Payer: Global Benefits Group Commercial |
$1,717.18
|
| Rate for Payer: Health Management Network EPO/PPO |
$2,575.76
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,908.93
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$572.39
|
| Rate for Payer: Multiplan Commercial |
$2,146.47
|
| Rate for Payer: Networks By Design Commercial |
$1,430.98
|
| Rate for Payer: Prime Health Services Commercial |
$2,432.67
|
|
|
ROMIPLOSTIM 500 MCG SUBCUTANEOUS SOLUTION [93567]
|
Facility
IP
|
$5,723.92
|
|
|
Service Code
|
CPT J2796
|
| Hospital Charge Code |
1721176
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,144.78 |
| Max. Negotiated Rate |
$5,151.53 |
| Rate for Payer: Blue Shield of California Commercial |
$4,292.94
|
| Rate for Payer: Blue Shield of California EPN |
$3,056.57
|
| Rate for Payer: Cash Price |
$2,575.76
|
| Rate for Payer: Central Health Plan Commercial |
$4,579.14
|
| Rate for Payer: Cigna of CA HMO |
$4,006.74
|
| Rate for Payer: Cigna of CA PPO |
$4,006.74
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,289.57
|
| Rate for Payer: EPIC Health Plan Transplant |
$2,289.57
|
| Rate for Payer: Galaxy Health WC |
$4,865.33
|
| Rate for Payer: Global Benefits Group Commercial |
$3,434.35
|
| Rate for Payer: Health Management Network EPO/PPO |
$5,151.53
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3,817.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,144.78
|
| Rate for Payer: Multiplan Commercial |
$4,292.94
|
| Rate for Payer: Networks By Design Commercial |
$2,861.96
|
| Rate for Payer: Prime Health Services Commercial |
$4,865.33
|
|
|
ROMIPLOSTIM 500 MCG SUBCUTANEOUS SOLUTION [93567]
|
Facility
OP
|
$5,723.92
|
|
|
Service Code
|
CPT J2796
|
| Hospital Charge Code |
1721176
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$85.82 |
| Max. Negotiated Rate |
$5,151.53 |
| Rate for Payer: Adventist Health Medi-Cal |
$96.03
|
| Rate for Payer: Aetna of CA HMO/PPO |
$595.10
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$120.03
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$105.63
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$105.63
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$85.82
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$93.96
|
| Rate for Payer: BCBS Transplant Transplant |
$3,434.35
|
| Rate for Payer: Blue Shield of California Commercial |
$102.94
|
| Rate for Payer: Blue Shield of California EPN |
$93.58
|
| Rate for Payer: Caremore Medicare Advantage |
$96.03
|
| Rate for Payer: Cash Price |
$2,575.76
|
| Rate for Payer: Cash Price |
$2,575.76
|
| Rate for Payer: Central Health Plan Commercial |
$4,579.14
|
| Rate for Payer: Cigna of CA HMO |
$4,006.74
|
| Rate for Payer: Cigna of CA PPO |
$4,006.74
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$144.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$129.64
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$96.03
|
| Rate for Payer: EPIC Health Plan Transplant |
$96.03
|
| Rate for Payer: Galaxy Health WC |
$4,865.33
|
| Rate for Payer: Global Benefits Group Commercial |
$3,434.35
|
| Rate for Payer: Health Management Network EPO/PPO |
$5,151.53
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$4,292.94
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$157.48
|
| Rate for Payer: IEHP medi-cal |
$158.44
|
| Rate for Payer: IEHP Medicare Advantage |
$96.03
|
| Rate for Payer: Innovage PACE Commercial |
$144.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3,817.85
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$96.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,144.78
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$128.68
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$128.68
|
| Rate for Payer: Multiplan Commercial |
$4,292.94
|
| Rate for Payer: Networks By Design Commercial |
$2,861.96
|
| Rate for Payer: Prime Health Services Commercial |
$4,865.33
|
| Rate for Payer: Prime Health Services Medicare |
$101.79
|
| Rate for Payer: Riverside University Health MISP |
$105.63
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3,434.35
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3,434.35
|
| Rate for Payer: United Healthcare All Other Commercial |
$2,861.96
|
| Rate for Payer: United Healthcare All Other HMO |
$2,861.96
|
| Rate for Payer: United Healthcare HMO Rider |
$2,861.96
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2,861.96
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$144.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$105.63
|
| Rate for Payer: Vantage Medical Group Senior |
$96.03
|
|
|
ROPINIROLE 0.25 MG TABLET [21688]
|
Facility
IP
|
$0.59
|
|
|
Service Code
|
NDC 0904-6373-61
|
| Hospital Charge Code |
1711813
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.53 |
| Rate for Payer: Blue Shield of California Commercial |
$0.44
|
| Rate for Payer: Blue Shield of California EPN |
$0.32
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Central Health Plan Commercial |
$0.47
|
| Rate for Payer: Cigna of CA HMO |
$0.41
|
| Rate for Payer: Cigna of CA PPO |
$0.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.24
|
| Rate for Payer: Galaxy Health WC |
$0.50
|
| Rate for Payer: Global Benefits Group Commercial |
$0.35
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.53
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.44
|
| Rate for Payer: Networks By Design Commercial |
$0.38
|
| Rate for Payer: Prime Health Services Commercial |
$0.50
|
|
|
ROPINIROLE 0.25 MG TABLET [21688]
|
Facility
IP
|
$0.66
|
|
|
Service Code
|
NDC 60687-577-11
|
| Hospital Charge Code |
1711813
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.59 |
| Rate for Payer: Blue Shield of California Commercial |
$0.50
|
| Rate for Payer: Blue Shield of California EPN |
$0.35
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Central Health Plan Commercial |
$0.53
|
| Rate for Payer: Cigna of CA HMO |
$0.46
|
| Rate for Payer: Cigna of CA PPO |
$0.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.26
|
| Rate for Payer: Galaxy Health WC |
$0.56
|
| Rate for Payer: Global Benefits Group Commercial |
$0.40
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.59
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.50
|
| Rate for Payer: Networks By Design Commercial |
$0.43
|
| Rate for Payer: Prime Health Services Commercial |
$0.56
|
|
