|
DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION [27103]
|
Facility
|
OP
|
$6.75
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.35 |
| Max. Negotiated Rate |
$6.08 |
| Rate for Payer: Adventist Health Commercial |
$1.35
|
| Rate for Payer: Adventist Health Commercial |
$2.88
|
| Rate for Payer: Aetna of CA HMO/PPO |
$8.75
|
| Rate for Payer: Aetna of CA HMO/PPO |
$4.10
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.74
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$12.24
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7.92
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.71
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$10.80
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.06
|
| Rate for Payer: Blue Shield of California Commercial |
$4.28
|
| Rate for Payer: Blue Shield of California Commercial |
$9.13
|
| Rate for Payer: Blue Shield of California EPN |
$2.69
|
| Rate for Payer: Blue Shield of California EPN |
$5.75
|
| Rate for Payer: Cash Price |
$6.48
|
| Rate for Payer: Cash Price |
$3.04
|
| Rate for Payer: Central Health Plan Commercial |
$11.52
|
| Rate for Payer: Central Health Plan Commercial |
$5.40
|
| Rate for Payer: Cigna of CA HMO |
$4.72
|
| Rate for Payer: Cigna of CA HMO |
$10.08
|
| Rate for Payer: Cigna of CA PPO |
$10.08
|
| Rate for Payer: Cigna of CA PPO |
$4.72
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.74
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$12.24
|
| Rate for Payer: Dignity Health Medi-Cal |
$12.24
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.74
|
| Rate for Payer: Dignity Health Medicare Advantage |
$5.74
|
| Rate for Payer: Dignity Health Medicare Advantage |
$12.24
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$4.72
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$10.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.70
|
| Rate for Payer: EPIC Health Plan Senior |
$2.70
|
| Rate for Payer: EPIC Health Plan Senior |
$5.76
|
| Rate for Payer: Galaxy Health WC |
$12.24
|
| Rate for Payer: Galaxy Health WC |
$5.74
|
| Rate for Payer: Global Benefits Group Commercial |
$8.64
|
| Rate for Payer: Global Benefits Group Commercial |
$4.05
|
| Rate for Payer: Health Management Network EPO/PPO |
$6.08
|
| Rate for Payer: Health Management Network EPO/PPO |
$12.96
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$9.14
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$4.29
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$3.98
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$8.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.35
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$4.72
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$10.08
|
| Rate for Payer: Multiplan Commercial |
$10.80
|
| Rate for Payer: Multiplan Commercial |
$5.06
|
| Rate for Payer: Networks By Design Commercial |
$3.38
|
| Rate for Payer: Networks By Design Commercial |
$7.20
|
| Rate for Payer: Prime Health Services Commercial |
$5.74
|
| Rate for Payer: Prime Health Services Commercial |
$12.24
|
| Rate for Payer: Riverside University Health System MISP |
$2.70
|
| Rate for Payer: Riverside University Health System MISP |
$5.76
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$8.64
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$4.05
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$8.64
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$4.05
|
| Rate for Payer: United Healthcare All Other Commercial |
$5.40
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.53
|
| Rate for Payer: United Healthcare All Other HMO |
$5.26
|
| Rate for Payer: United Healthcare All Other HMO |
$2.47
|
| Rate for Payer: United Healthcare HMO Rider |
$5.15
|
| Rate for Payer: United Healthcare HMO Rider |
$2.41
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.21
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4.72
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.74
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$12.24
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$12.24
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.74
|
| Rate for Payer: Vantage Medical Group Senior |
$12.24
|
| Rate for Payer: Vantage Medical Group Senior |
$5.74
|
|
|
DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION [27103]
|
Facility
|
IP
|
$6.75
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.35 |
| Max. Negotiated Rate |
$6.08 |
| Rate for Payer: Adventist Health Commercial |
$1.35
|
| Rate for Payer: Adventist Health Commercial |
$2.88
|
| Rate for Payer: Blue Shield of California Commercial |
$5.41
|
| Rate for Payer: Blue Shield of California Commercial |
$11.55
|
| Rate for Payer: Blue Shield of California EPN |
$7.26
|
| Rate for Payer: Blue Shield of California EPN |
$3.40
|
| Rate for Payer: Cash Price |
$3.04
|
| Rate for Payer: Cash Price |
$6.48
|
| Rate for Payer: Central Health Plan Commercial |
$5.40
|
| Rate for Payer: Central Health Plan Commercial |
$11.52
|
| Rate for Payer: Cigna of CA HMO |
$10.08
|
| Rate for Payer: Cigna of CA HMO |
$4.72
|
| Rate for Payer: Cigna of CA PPO |
$10.08
|
| Rate for Payer: Cigna of CA PPO |
$4.72
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$10.08
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$4.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.70
|
| Rate for Payer: EPIC Health Plan Senior |
$5.76
|
| Rate for Payer: EPIC Health Plan Senior |
$2.70
|
| Rate for Payer: Galaxy Health WC |
$5.74
|
| Rate for Payer: Galaxy Health WC |
$12.24
|
| Rate for Payer: Global Benefits Group Commercial |
$8.64
|
| Rate for Payer: Global Benefits Group Commercial |
$4.05
|
| Rate for Payer: Health Management Network EPO/PPO |
$12.96
|
| Rate for Payer: Health Management Network EPO/PPO |
$6.08
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$4.29
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$9.14
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$8.50
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$3.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.88
|
| Rate for Payer: Multiplan Commercial |
$10.80
|
| Rate for Payer: Multiplan Commercial |
$5.06
|
| Rate for Payer: Networks By Design Commercial |
$7.20
|
| Rate for Payer: Networks By Design Commercial |
$3.38
|
| Rate for Payer: Prime Health Services Commercial |
$5.74
|
| Rate for Payer: Prime Health Services Commercial |
$12.24
|
| Rate for Payer: United Healthcare All Other Commercial |
$5.40
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.53
|
| Rate for Payer: United Healthcare All Other HMO |
$2.47
|
| Rate for Payer: United Healthcare All Other HMO |
$5.26
|
| Rate for Payer: United Healthcare HMO Rider |
$5.15
|
| Rate for Payer: United Healthcare HMO Rider |
$2.41
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4.72
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.21
|
|
|
DEXMEDETOMIDINE 200 MCG/50 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV [201902]
|
Facility
|
IP
|
$0.62
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.56 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Blue Shield of California Commercial |
$0.50
|
| Rate for Payer: Blue Shield of California EPN |
$0.31
|
| Rate for Payer: Cash Price |
$0.28
|
| Rate for Payer: Central Health Plan Commercial |
$0.50
|
| Rate for Payer: Cigna of CA HMO |
$0.43
|
| Rate for Payer: Cigna of CA PPO |
$0.43
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.25
|
| Rate for Payer: EPIC Health Plan Senior |
$0.25
|
| Rate for Payer: Galaxy Health WC |
$0.53
|
| Rate for Payer: Global Benefits Group Commercial |
$0.37
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.56
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.39
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.47
|
| Rate for Payer: Networks By Design Commercial |
$0.31
|
| Rate for Payer: Prime Health Services Commercial |
$0.53
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.23
|
| Rate for Payer: United Healthcare All Other HMO |
$0.23
|
| Rate for Payer: United Healthcare HMO Rider |
$0.22
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.20
|
|
|
DEXMEDETOMIDINE 200 MCG/50 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV [201902]
|
Facility
|
OP
|
$0.62
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.56 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.38
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.53
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.34
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.47
|
| Rate for Payer: Blue Shield of California Commercial |
$0.39
|
| Rate for Payer: Blue Shield of California EPN |
$0.25
|
| Rate for Payer: Cash Price |
$0.28
|
| Rate for Payer: Central Health Plan Commercial |
$0.50
|
| Rate for Payer: Cigna of CA HMO |
$0.43
|
| Rate for Payer: Cigna of CA PPO |
$0.43
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.53
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.53
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.53
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.25
|
| Rate for Payer: EPIC Health Plan Senior |
$0.25
|
| Rate for Payer: Galaxy Health WC |
$0.53
|
| Rate for Payer: Global Benefits Group Commercial |
$0.37
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.56
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.39
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.43
|
| Rate for Payer: Multiplan Commercial |
$0.47
|
| Rate for Payer: Networks By Design Commercial |
$0.31
|
| Rate for Payer: Prime Health Services Commercial |
$0.53
|
| Rate for Payer: Riverside University Health System MISP |
$0.25
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.37
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.37
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.23
|
| Rate for Payer: United Healthcare All Other HMO |
$0.23
|
| Rate for Payer: United Healthcare HMO Rider |
$0.22
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.20
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.53
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.53
|
| Rate for Payer: Vantage Medical Group Senior |
$0.53
|
|
|
DEXMEDETOMIDINE 400 MCG/100 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV [201904]
|
Facility
|
OP
|
$0.41
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.37 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.25
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.35
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.23
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.31
|
| Rate for Payer: Blue Shield of California Commercial |
$0.26
|
| Rate for Payer: Blue Shield of California EPN |
$0.16
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Central Health Plan Commercial |
$0.33
|
| 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 |
$0.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.35
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.35
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| Rate for Payer: EPIC Health Plan Senior |
$0.16
|
| Rate for Payer: Galaxy Health WC |
$0.35
|
| Rate for Payer: Global Benefits Group Commercial |
$0.25
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.37
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.26
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.29
|
| Rate for Payer: Multiplan Commercial |
$0.31
|
| Rate for Payer: Networks By Design Commercial |
$0.21
|
| Rate for Payer: Prime Health Services Commercial |
$0.35
|
| Rate for Payer: Riverside University Health System MISP |
$0.16
|
| 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 |
$0.15
|
| Rate for Payer: United Healthcare All Other HMO |
$0.15
|
| Rate for Payer: United Healthcare HMO Rider |
$0.15
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.13
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.35
|
| Rate for Payer: Vantage Medical Group Senior |
$0.35
|
|
|
DEXMEDETOMIDINE 400 MCG/100 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV [201904]
|
Facility
|
IP
|
$0.41
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.37 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Blue Shield of California Commercial |
$0.33
|
| Rate for Payer: Blue Shield of California EPN |
$0.21
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Central Health Plan Commercial |
$0.33
|
| Rate for Payer: Cigna of CA HMO |
$0.29
|
| Rate for Payer: Cigna of CA PPO |
$0.29
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| Rate for Payer: EPIC Health Plan Senior |
$0.16
|
| Rate for Payer: Galaxy Health WC |
$0.35
|
| Rate for Payer: Global Benefits Group Commercial |
$0.25
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.37
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.26
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.31
|
| Rate for Payer: Networks By Design Commercial |
$0.21
|
| Rate for Payer: Prime Health Services Commercial |
$0.35
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.15
|
| Rate for Payer: United Healthcare All Other HMO |
$0.15
|
| Rate for Payer: United Healthcare HMO Rider |
$0.15
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.13
|
|
|
DEXMEDETOMIDINE (PF) 100 MCG/ML INTRAVENOUS SOLUTION [249449]
|
Facility
|
IP
|
$3.15
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.63 |
| Max. Negotiated Rate |
$2.83 |
| Rate for Payer: Adventist Health Commercial |
$0.63
|
| Rate for Payer: Adventist Health Commercial |
$0.86
|
| Rate for Payer: Adventist Health Commercial |
$0.65
|
| Rate for Payer: Adventist Health Commercial |
$0.40
|
| Rate for Payer: Blue Shield of California Commercial |
$2.53
|
| Rate for Payer: Blue Shield of California Commercial |
$1.62
|
| Rate for Payer: Blue Shield of California Commercial |
$3.46
|
| Rate for Payer: Blue Shield of California Commercial |
$2.61
|
| Rate for Payer: Blue Shield of California EPN |
$1.59
|
| Rate for Payer: Blue Shield of California EPN |
$1.02
|
| Rate for Payer: Blue Shield of California EPN |
$1.64
|
| Rate for Payer: Blue Shield of California EPN |
$2.18
|
| Rate for Payer: Cash Price |
$1.94
|
| Rate for Payer: Cash Price |
$0.91
|
| Rate for Payer: Cash Price |
$1.46
|
| Rate for Payer: Cash Price |
$1.42
|
| Rate for Payer: Central Health Plan Commercial |
$3.46
|
| Rate for Payer: Central Health Plan Commercial |
$2.52
|
| Rate for Payer: Central Health Plan Commercial |
$1.62
|
| Rate for Payer: Central Health Plan Commercial |
$2.60
|
| Rate for Payer: Cigna of CA HMO |
$2.21
|
| Rate for Payer: Cigna of CA HMO |
$2.27
|
| Rate for Payer: Cigna of CA HMO |
$3.02
|
| Rate for Payer: Cigna of CA HMO |
$1.41
|
| Rate for Payer: Cigna of CA PPO |
$1.41
|
| Rate for Payer: Cigna of CA PPO |
$2.21
|
| Rate for Payer: Cigna of CA PPO |
$2.27
|
| Rate for Payer: Cigna of CA PPO |
$3.02
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.41
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$3.02
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$2.27
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$2.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.73
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.81
|
| Rate for Payer: EPIC Health Plan Senior |
$1.26
|
| Rate for Payer: EPIC Health Plan Senior |
$1.30
|
| Rate for Payer: EPIC Health Plan Senior |
$1.73
|
| Rate for Payer: EPIC Health Plan Senior |
$0.81
|
| Rate for Payer: Galaxy Health WC |
$2.76
|
| Rate for Payer: Galaxy Health WC |
$1.72
|
| Rate for Payer: Galaxy Health WC |
$2.68
|
| Rate for Payer: Galaxy Health WC |
$3.67
|
| Rate for Payer: Global Benefits Group Commercial |
$2.59
|
| Rate for Payer: Global Benefits Group Commercial |
$1.89
|
| Rate for Payer: Global Benefits Group Commercial |
$1.95
|
| Rate for Payer: Global Benefits Group Commercial |
$1.21
|
| Rate for Payer: Health Management Network EPO/PPO |
$3.89
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.83
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.92
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.82
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$2.74
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$2.00
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$2.06
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.28
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.86
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2.55
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.92
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.65
|
| Rate for Payer: Multiplan Commercial |
$3.24
|
| Rate for Payer: Multiplan Commercial |
$2.36
|
| Rate for Payer: Multiplan Commercial |
$1.51
|
| Rate for Payer: Multiplan Commercial |
$2.44
|
| Rate for Payer: Networks By Design Commercial |
$2.16
|
| Rate for Payer: Networks By Design Commercial |
$1.01
|
| Rate for Payer: Networks By Design Commercial |
$1.62
|
| Rate for Payer: Networks By Design Commercial |
$1.57
|
| Rate for Payer: Prime Health Services Commercial |
$2.76
|
| Rate for Payer: Prime Health Services Commercial |
$2.68
|
| Rate for Payer: Prime Health Services Commercial |
$1.72
|
| Rate for Payer: Prime Health Services Commercial |
$3.67
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.62
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.22
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.76
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.18
|
| Rate for Payer: United Healthcare All Other HMO |
$1.15
|
| Rate for Payer: United Healthcare All Other HMO |
$0.74
|
| Rate for Payer: United Healthcare All Other HMO |
$1.58
|
| Rate for Payer: United Healthcare All Other HMO |
$1.19
|
| Rate for Payer: United Healthcare HMO Rider |
$0.72
|
| Rate for Payer: United Healthcare HMO Rider |
$1.16
|
| Rate for Payer: United Healthcare HMO Rider |
$1.54
|
| Rate for Payer: United Healthcare HMO Rider |
$1.13
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.41
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.66
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.03
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.06
|
|
|
DEXMEDETOMIDINE (PF) 100 MCG/ML INTRAVENOUS SOLUTION [249449]
|
Facility
|
OP
|
$2.02
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.40 |
| Max. Negotiated Rate |
$1.82 |
| Rate for Payer: Adventist Health Commercial |
$0.40
|
| Rate for Payer: Adventist Health Commercial |
$0.86
|
| Rate for Payer: Adventist Health Commercial |
$0.65
|
| Rate for Payer: Adventist Health Commercial |
$0.63
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.97
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.91
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.23
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2.62
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.68
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.67
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.76
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.72
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.73
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.79
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.11
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.38
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.36
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.51
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.24
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.44
|
| Rate for Payer: Blue Shield of California Commercial |
$2.06
|
| Rate for Payer: Blue Shield of California Commercial |
$1.28
|
| Rate for Payer: Blue Shield of California Commercial |
$2.74
|
| Rate for Payer: Blue Shield of California Commercial |
$2.00
|
| Rate for Payer: Blue Shield of California EPN |
$0.81
|
| Rate for Payer: Blue Shield of California EPN |
$1.30
|
| Rate for Payer: Blue Shield of California EPN |
$1.72
|
| Rate for Payer: Blue Shield of California EPN |
$1.26
|
| Rate for Payer: Cash Price |
$1.94
|
| Rate for Payer: Cash Price |
$1.46
|
| Rate for Payer: Cash Price |
$0.91
|
| Rate for Payer: Cash Price |
$1.42
|
| Rate for Payer: Central Health Plan Commercial |
$2.60
|
| Rate for Payer: Central Health Plan Commercial |
$2.52
|
| Rate for Payer: Central Health Plan Commercial |
$1.62
|
| Rate for Payer: Central Health Plan Commercial |
$3.46
|
| Rate for Payer: Cigna of CA HMO |
$2.27
|
| Rate for Payer: Cigna of CA HMO |
$2.21
|
| Rate for Payer: Cigna of CA HMO |
$1.41
|
| Rate for Payer: Cigna of CA HMO |
$3.02
|
| Rate for Payer: Cigna of CA PPO |
$3.02
|
| Rate for Payer: Cigna of CA PPO |
$2.21
|
| Rate for Payer: Cigna of CA PPO |
$1.41
|
| Rate for Payer: Cigna of CA PPO |
$2.27
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.72
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.67
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.68
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.76
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.72
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.67
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.76
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.68
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3.67
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.76
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.72
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.68
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$2.27
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$2.21
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$3.02
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.81
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.73
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.26
|
| Rate for Payer: EPIC Health Plan Senior |
$1.30
|
| Rate for Payer: EPIC Health Plan Senior |
$1.26
|
| Rate for Payer: EPIC Health Plan Senior |
$0.81
|
| Rate for Payer: EPIC Health Plan Senior |
$1.73
|
| Rate for Payer: Galaxy Health WC |
$1.72
|
| Rate for Payer: Galaxy Health WC |
$2.76
|
| Rate for Payer: Galaxy Health WC |
$3.67
|
| Rate for Payer: Galaxy Health WC |
$2.68
|
| Rate for Payer: Global Benefits Group Commercial |
$2.59
|
| Rate for Payer: Global Benefits Group Commercial |
$1.89
|
| Rate for Payer: Global Benefits Group Commercial |
$1.21
|
| Rate for Payer: Global Benefits Group Commercial |
$1.95
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.92
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.82
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.83
|
| Rate for Payer: Health Management Network EPO/PPO |
$3.89
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$2.74
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$2.00
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.28
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$2.06
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.92
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2.55
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.86
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.40
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$3.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$2.27
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$2.21
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1.41
|
| Rate for Payer: Multiplan Commercial |
$2.36
|
| Rate for Payer: Multiplan Commercial |
$3.24
|
| Rate for Payer: Multiplan Commercial |
$2.44
|
| Rate for Payer: Multiplan Commercial |
$1.51
|
| Rate for Payer: Networks By Design Commercial |
$1.01
|
| Rate for Payer: Networks By Design Commercial |
$2.16
|
| Rate for Payer: Networks By Design Commercial |
$1.62
|
| Rate for Payer: Networks By Design Commercial |
$1.57
|
| Rate for Payer: Prime Health Services Commercial |
$2.76
|
| Rate for Payer: Prime Health Services Commercial |
$1.72
|
| Rate for Payer: Prime Health Services Commercial |
$2.68
|
| Rate for Payer: Prime Health Services Commercial |
$3.67
|
| Rate for Payer: Riverside University Health System MISP |
$1.73
|
| Rate for Payer: Riverside University Health System MISP |
$1.30
|
| Rate for Payer: Riverside University Health System MISP |
$0.81
|
| Rate for Payer: Riverside University Health System MISP |
$1.26
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.95
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.59
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.89
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.21
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.59
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.95
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.21
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.89
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.76
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.18
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.62
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.22
|
| Rate for Payer: United Healthcare All Other HMO |
$1.58
|
| Rate for Payer: United Healthcare All Other HMO |
$1.15
|
| Rate for Payer: United Healthcare All Other HMO |
$1.19
|
| Rate for Payer: United Healthcare All Other HMO |
$0.74
|
| Rate for Payer: United Healthcare HMO Rider |
$1.16
|
| Rate for Payer: United Healthcare HMO Rider |
$1.54
|
| Rate for Payer: United Healthcare HMO Rider |
$1.13
|
| Rate for Payer: United Healthcare HMO Rider |
$0.72
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.41
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.06
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.66
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.03
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.67
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.72
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.76
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.68
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.67
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.76
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.72
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.68
|
| Rate for Payer: Vantage Medical Group Senior |
$1.72
|
| Rate for Payer: Vantage Medical Group Senior |
$3.67
|
| Rate for Payer: Vantage Medical Group Senior |
$2.76
|
| Rate for Payer: Vantage Medical Group Senior |
$2.68
|
|
|
DEXRAZOXANE (CARDIOXANE) HCL 500 MG INTRAVENOUS [40815157]
|
Facility
|
OP
|
$455.94
|
|
|
Service Code
|
HCPCS J1190
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$41.44 |
| Max. Negotiated Rate |
$489.83 |
| Rate for Payer: Adventist Health Commercial |
$91.19
|
| Rate for Payer: Adventist Health Medi-Cal |
$41.44
|
| Rate for Payer: Aetna of CA HMO/PPO |
$159.45
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$51.80
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$45.58
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$45.58
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$392.52
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$489.83
|
| Rate for Payer: Blue Shield of California Commercial |
$321.82
|
| Rate for Payer: Blue Shield of California EPN |
$292.56
|
| Rate for Payer: Cash Price |
$205.17
|
| Rate for Payer: Cash Price |
$205.17
|
| Rate for Payer: Central Health Plan Commercial |
$364.75
|
| Rate for Payer: Cigna of CA HMO |
$319.16
|
| Rate for Payer: Cigna of CA PPO |
$319.16
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$51.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$45.58
|
| Rate for Payer: Dignity Health Medicare Advantage |
$45.58
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$319.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$68.38
|
| Rate for Payer: EPIC Health Plan Senior |
$45.58
|
| Rate for Payer: Galaxy Health WC |
$387.55
|
| Rate for Payer: Global Benefits Group Commercial |
$273.56
|
| Rate for Payer: Health Management Network EPO/PPO |
$410.35
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$67.96
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$41.44
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$41.44
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$289.52
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$165.51
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$58.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$91.19
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$55.53
|
| Rate for Payer: Multiplan Commercial |
$341.95
|
| Rate for Payer: Networks By Design Commercial |
$227.97
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$41.44
|
| Rate for Payer: Prime Health Services Commercial |
$387.55
|
| Rate for Payer: Prime Health Services Medicare |
$43.93
|
| Rate for Payer: Riverside University Health System MISP |
$45.58
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$273.56
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$273.56
|
| Rate for Payer: United Healthcare All Other Commercial |
$171.11
|
| Rate for Payer: United Healthcare All Other HMO |
$166.55
|
| Rate for Payer: United Healthcare HMO Rider |
$162.95
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$149.32
|
| Rate for Payer: Upland Medical Group Pediatric |
$41.44
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$51.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$45.58
|
| Rate for Payer: Vantage Medical Group Senior |
$45.58
|
|
|
DEXRAZOXANE (CARDIOXANE) HCL 500 MG INTRAVENOUS [40815157]
|
Facility
|
IP
|
$455.94
|
|
|
Service Code
|
HCPCS J1190
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$91.19 |
| Max. Negotiated Rate |
$410.35 |
| Rate for Payer: Adventist Health Commercial |
$91.19
|
| Rate for Payer: Blue Shield of California Commercial |
$365.66
|
| Rate for Payer: Blue Shield of California EPN |
$229.79
|
| Rate for Payer: Cash Price |
$205.17
|
| Rate for Payer: Central Health Plan Commercial |
$364.75
|
| Rate for Payer: Cigna of CA HMO |
$319.16
|
| Rate for Payer: Cigna of CA PPO |
$319.16
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$319.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$182.38
|
| Rate for Payer: EPIC Health Plan Senior |
$182.38
|
| Rate for Payer: Galaxy Health WC |
$387.55
|
| Rate for Payer: Global Benefits Group Commercial |
$273.56
|
| Rate for Payer: Health Management Network EPO/PPO |
$410.35
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$289.52
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$269.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$91.19
|
| Rate for Payer: Multiplan Commercial |
$341.95
|
| Rate for Payer: Networks By Design Commercial |
$227.97
|
| Rate for Payer: Prime Health Services Commercial |
$387.55
|
| Rate for Payer: United Healthcare All Other Commercial |
$171.11
|
| Rate for Payer: United Healthcare All Other HMO |
$166.55
|
| Rate for Payer: United Healthcare HMO Rider |
$162.95
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$149.32
|
|
|
DEXRAZOXANE HCL 250 MG INTRAVENOUS SOLUTION [15156]
|
Facility
|
IP
|
$329.11
|
|
|
Service Code
|
HCPCS J1190
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$65.82 |
| Max. Negotiated Rate |
$296.20 |
| Rate for Payer: Adventist Health Commercial |
$65.82
|
| Rate for Payer: Blue Shield of California Commercial |
$263.95
|
| Rate for Payer: Blue Shield of California EPN |
$165.87
|
| Rate for Payer: Cash Price |
$148.10
|
| Rate for Payer: Central Health Plan Commercial |
$263.29
|
| Rate for Payer: Cigna of CA HMO |
$230.38
|
| Rate for Payer: Cigna of CA PPO |
$230.38
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$230.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$131.64
|
| Rate for Payer: EPIC Health Plan Senior |
$131.64
|
| Rate for Payer: Galaxy Health WC |
$279.74
|
| Rate for Payer: Global Benefits Group Commercial |
$197.47
|
| Rate for Payer: Health Management Network EPO/PPO |
$296.20
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$208.98
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$194.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$65.82
|
| Rate for Payer: Multiplan Commercial |
$246.83
|
| Rate for Payer: Networks By Design Commercial |
$164.56
|
| Rate for Payer: Prime Health Services Commercial |
$279.74
|
| Rate for Payer: United Healthcare All Other Commercial |
$123.51
|
| Rate for Payer: United Healthcare All Other HMO |
$120.22
|
| Rate for Payer: United Healthcare HMO Rider |
$117.62
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$107.78
|
|
|
DEXRAZOXANE HCL 250 MG INTRAVENOUS SOLUTION [15156]
|
Facility
|
OP
|
$329.11
|
|
|
Service Code
|
HCPCS J1190
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$41.44 |
| Max. Negotiated Rate |
$489.83 |
| Rate for Payer: Adventist Health Commercial |
$65.82
|
| Rate for Payer: Adventist Health Medi-Cal |
$41.44
|
| Rate for Payer: Aetna of CA HMO/PPO |
$159.45
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$51.80
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$45.58
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$45.58
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$392.52
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$489.83
|
| Rate for Payer: Blue Shield of California Commercial |
$321.82
|
| Rate for Payer: Blue Shield of California EPN |
$292.56
|
| Rate for Payer: Cash Price |
$148.10
|
| Rate for Payer: Cash Price |
$148.10
|
| Rate for Payer: Central Health Plan Commercial |
$263.29
|
| Rate for Payer: Cigna of CA HMO |
$230.38
|
| Rate for Payer: Cigna of CA PPO |
$230.38
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$51.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$45.58
|
| Rate for Payer: Dignity Health Medicare Advantage |
$45.58
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$230.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$68.38
|
| Rate for Payer: EPIC Health Plan Senior |
$45.58
|
| Rate for Payer: Galaxy Health WC |
$279.74
|
| Rate for Payer: Global Benefits Group Commercial |
$197.47
|
| Rate for Payer: Health Management Network EPO/PPO |
$296.20
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$67.96
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$41.44
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$41.44
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$208.98
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$119.47
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$58.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$65.82
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$55.53
|
| Rate for Payer: Multiplan Commercial |
$246.83
|
| Rate for Payer: Networks By Design Commercial |
$164.56
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$41.44
|
| Rate for Payer: Prime Health Services Commercial |
$279.74
|
| Rate for Payer: Prime Health Services Medicare |
$43.93
|
| Rate for Payer: Riverside University Health System MISP |
$45.58
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$197.47
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$197.47
|
| Rate for Payer: United Healthcare All Other Commercial |
$123.51
|
| Rate for Payer: United Healthcare All Other HMO |
$120.22
|
| Rate for Payer: United Healthcare HMO Rider |
$117.62
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$107.78
|
| Rate for Payer: Upland Medical Group Pediatric |
$41.44
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$51.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$45.58
|
| Rate for Payer: Vantage Medical Group Senior |
$45.58
|
|
|
DEXTRAN 70-HYPROMELLOSE (PF) 0.1 %-0.3 % EYE DROPS IN A DROPPERETTE [120696]
|
Facility
|
IP
|
$0.30
|
|
|
Service Code
|
NDC 0065041663
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.27 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California Commercial |
$0.24
|
| Rate for Payer: Blue Shield of California EPN |
$0.15
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Central Health Plan Commercial |
$0.24
|
| Rate for Payer: Cigna of CA HMO |
$0.21
|
| Rate for Payer: Cigna of CA PPO |
$0.21
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: EPIC Health Plan Senior |
$0.12
|
| Rate for Payer: Galaxy Health WC |
$0.26
|
| Rate for Payer: Global Benefits Group Commercial |
$0.18
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.27
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.19
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
| Rate for Payer: Networks By Design Commercial |
$0.20
|
| Rate for Payer: Prime Health Services Commercial |
$0.26
|
|
|
DEXTRAN 70-HYPROMELLOSE (PF) 0.1 %-0.3 % EYE DROPS IN A DROPPERETTE [120696]
|
Facility
|
OP
|
$0.30
|
|
|
Service Code
|
NDC 0065041663
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.27 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.18
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.26
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.17
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.23
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.15
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.17
|
| Rate for Payer: Blue Shield of California Commercial |
$0.19
|
| Rate for Payer: Blue Shield of California EPN |
$0.12
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Central Health Plan Commercial |
$0.24
|
| Rate for Payer: Cigna of CA HMO |
$0.21
|
| Rate for Payer: Cigna of CA PPO |
$0.21
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.26
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.26
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: EPIC Health Plan Senior |
$0.12
|
| Rate for Payer: Galaxy Health WC |
$0.26
|
| Rate for Payer: Global Benefits Group Commercial |
$0.18
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.27
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.19
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.11
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.21
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
| Rate for Payer: Networks By Design Commercial |
$0.20
|
| Rate for Payer: Prime Health Services Commercial |
$0.26
|
| Rate for Payer: Riverside University Health System MISP |
$0.12
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.18
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.18
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.15
|
| Rate for Payer: United Healthcare All Other HMO |
$0.15
|
| Rate for Payer: United Healthcare HMO Rider |
$0.15
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.15
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.26
|
| Rate for Payer: Vantage Medical Group Senior |
$0.26
|
|
|
DEXTRAN 70-HYPROMELLOSE (PF) 0.1 %-0.3 % EYE DROPS IN A DROPPERETTE [120696]
|
Facility
|
OP
|
$0.25
|
|
|
Service Code
|
NDC 0065041622
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.15
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.21
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.19
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.12
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.15
|
| Rate for Payer: Blue Shield of California Commercial |
$0.16
|
| Rate for Payer: Blue Shield of California EPN |
$0.10
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Central Health Plan Commercial |
$0.20
|
| Rate for Payer: Cigna of CA HMO |
$0.18
|
| Rate for Payer: Cigna of CA PPO |
$0.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.21
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.21
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: EPIC Health Plan Senior |
$0.10
|
| Rate for Payer: Galaxy Health WC |
$0.21
|
| Rate for Payer: Global Benefits Group Commercial |
$0.15
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.23
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.16
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.09
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.19
|
| Rate for Payer: Networks By Design Commercial |
$0.16
|
| Rate for Payer: Prime Health Services Commercial |
$0.21
|
| Rate for Payer: Riverside University Health System MISP |
$0.10
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.15
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.15
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.13
|
| Rate for Payer: United Healthcare All Other HMO |
$0.13
|
| Rate for Payer: United Healthcare HMO Rider |
$0.13
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.13
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.21
|
| Rate for Payer: Vantage Medical Group Senior |
$0.21
|
|
|
DEXTRAN 70-HYPROMELLOSE (PF) 0.1 %-0.3 % EYE DROPS IN A DROPPERETTE [120696]
|
Facility
|
IP
|
$0.33
|
|
|
Service Code
|
NDC 0065806301
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.30 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Blue Shield of California Commercial |
$0.26
|
| Rate for Payer: Blue Shield of California EPN |
$0.17
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Central Health Plan Commercial |
$0.26
|
| Rate for Payer: Cigna of CA HMO |
$0.23
|
| Rate for Payer: Cigna of CA PPO |
$0.23
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.13
|
| Rate for Payer: EPIC Health Plan Senior |
$0.13
|
| Rate for Payer: Galaxy Health WC |
$0.28
|
| Rate for Payer: Global Benefits Group Commercial |
$0.20
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.30
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.21
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.25
|
| Rate for Payer: Networks By Design Commercial |
$0.21
|
| Rate for Payer: Prime Health Services Commercial |
$0.28
|
|
|
DEXTRAN 70-HYPROMELLOSE (PF) 0.1 %-0.3 % EYE DROPS IN A DROPPERETTE [120696]
|
Facility
|
OP
|
$0.33
|
|
|
Service Code
|
NDC 0065806301
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.30 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.20
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.28
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.18
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.25
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.16
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.19
|
| Rate for Payer: Blue Shield of California Commercial |
$0.21
|
| Rate for Payer: Blue Shield of California EPN |
$0.13
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Central Health Plan Commercial |
$0.26
|
| Rate for Payer: Cigna of CA HMO |
$0.23
|
| Rate for Payer: Cigna of CA PPO |
$0.23
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.28
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.28
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.28
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.13
|
| Rate for Payer: EPIC Health Plan Senior |
$0.13
|
| Rate for Payer: Galaxy Health WC |
$0.28
|
| Rate for Payer: Global Benefits Group Commercial |
$0.20
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.30
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.21
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.12
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.23
|
| Rate for Payer: Multiplan Commercial |
$0.25
|
| Rate for Payer: Networks By Design Commercial |
$0.21
|
| Rate for Payer: Prime Health Services Commercial |
$0.28
|
| Rate for Payer: Riverside University Health System MISP |
$0.13
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.20
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.20
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.17
|
| Rate for Payer: United Healthcare All Other HMO |
$0.17
|
| Rate for Payer: United Healthcare HMO Rider |
$0.17
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.17
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.28
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.28
|
| Rate for Payer: Vantage Medical Group Senior |
$0.28
|
|
|
DEXTRAN 70-HYPROMELLOSE (PF) 0.1 %-0.3 % EYE DROPS IN A DROPPERETTE [120696]
|
Facility
|
IP
|
$0.25
|
|
|
Service Code
|
NDC 0065041622
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Blue Shield of California Commercial |
$0.20
|
| Rate for Payer: Blue Shield of California EPN |
$0.13
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Central Health Plan Commercial |
$0.20
|
| Rate for Payer: Cigna of CA HMO |
$0.18
|
| Rate for Payer: Cigna of CA PPO |
$0.18
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: EPIC Health Plan Senior |
$0.10
|
| Rate for Payer: Galaxy Health WC |
$0.21
|
| Rate for Payer: Global Benefits Group Commercial |
$0.15
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.23
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.16
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.19
|
| Rate for Payer: Networks By Design Commercial |
$0.16
|
| Rate for Payer: Prime Health Services Commercial |
$0.21
|
|
|
DEXTRANOMER 50MG-HYALURONATE 15MG/ML(1)-0.9%SODCHL GEL IMPLANT SYRINGE [227990]
|
Facility
|
IP
|
$3,966.00
|
|
|
Service Code
|
HCPCS L8604
|
| Hospital Charge Code |
901700050
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$793.20 |
| Max. Negotiated Rate |
$3,569.40 |
| Rate for Payer: Adventist Health Commercial |
$793.20
|
| Rate for Payer: Blue Shield of California Commercial |
$3,180.73
|
| Rate for Payer: Blue Shield of California EPN |
$1,998.86
|
| Rate for Payer: Cash Price |
$1,784.70
|
| Rate for Payer: Central Health Plan Commercial |
$3,172.80
|
| Rate for Payer: Cigna of CA HMO |
$2,776.20
|
| Rate for Payer: Cigna of CA PPO |
$2,776.20
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$2,776.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,586.40
|
| Rate for Payer: EPIC Health Plan Senior |
$1,586.40
|
| Rate for Payer: Galaxy Health WC |
$3,371.10
|
| Rate for Payer: Global Benefits Group Commercial |
$2,379.60
|
| Rate for Payer: Health Management Network EPO/PPO |
$3,569.40
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$2,518.41
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2,339.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$793.20
|
| Rate for Payer: Multiplan Commercial |
$2,974.50
|
| Rate for Payer: Networks By Design Commercial |
$1,983.00
|
| Rate for Payer: Prime Health Services Commercial |
$3,371.10
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,488.44
|
| Rate for Payer: United Healthcare All Other HMO |
$1,448.78
|
| Rate for Payer: United Healthcare HMO Rider |
$1,417.45
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,298.87
|
|
|
DEXTRANOMER 50MG-HYALURONATE 15MG/ML(1)-0.9%SODCHL GEL IMPLANT SYRINGE [227990]
|
Facility
|
OP
|
$3,966.00
|
|
|
Service Code
|
HCPCS L8604
|
| Hospital Charge Code |
901700050
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$793.20 |
| Max. Negotiated Rate |
$3,569.40 |
| Rate for Payer: Adventist Health Commercial |
$793.20
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,371.10
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,181.30
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,974.50
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1,810.88
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2,174.95
|
| Rate for Payer: Blue Shield of California Commercial |
$3,180.73
|
| Rate for Payer: Blue Shield of California EPN |
$1,998.86
|
| Rate for Payer: Cash Price |
$1,784.70
|
| Rate for Payer: Central Health Plan Commercial |
$3,172.80
|
| Rate for Payer: Cigna of CA HMO |
$2,776.20
|
| Rate for Payer: Cigna of CA PPO |
$2,776.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,371.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$3,371.10
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3,371.10
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$2,776.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,586.40
|
| Rate for Payer: EPIC Health Plan Senior |
$1,586.40
|
| Rate for Payer: Galaxy Health WC |
$3,371.10
|
| Rate for Payer: Global Benefits Group Commercial |
$2,379.60
|
| Rate for Payer: Health Management Network EPO/PPO |
$3,569.40
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$2,518.41
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2,339.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$793.20
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$2,776.20
|
| Rate for Payer: Multiplan Commercial |
$2,974.50
|
| Rate for Payer: Networks By Design Commercial |
$1,983.00
|
| Rate for Payer: Prime Health Services Commercial |
$3,371.10
|
| Rate for Payer: Riverside University Health System MISP |
$1,586.40
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2,379.60
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2,379.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,488.44
|
| Rate for Payer: United Healthcare All Other HMO |
$1,448.78
|
| Rate for Payer: United Healthcare HMO Rider |
$1,417.45
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,298.87
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,371.10
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3,371.10
|
| Rate for Payer: Vantage Medical Group Senior |
$3,371.10
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE 20 MG TABLET [111424]
|
Facility
|
OP
|
$0.45
|
|
|
Service Code
|
NDC 0185085301
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.41 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.27
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.38
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.25
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.34
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.22
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.26
|
| Rate for Payer: Blue Shield of California Commercial |
$0.29
|
| Rate for Payer: Blue Shield of California EPN |
$0.18
|
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: Central Health Plan Commercial |
$0.36
|
| Rate for Payer: Cigna of CA HMO |
$0.32
|
| Rate for Payer: Cigna of CA PPO |
$0.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.38
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.38
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.38
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.18
|
| Rate for Payer: EPIC Health Plan Senior |
$0.18
|
| Rate for Payer: Galaxy Health WC |
$0.38
|
| Rate for Payer: Global Benefits Group Commercial |
$0.27
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.41
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.29
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.16
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.32
|
| Rate for Payer: Multiplan Commercial |
$0.34
|
| Rate for Payer: Networks By Design Commercial |
$0.29
|
| Rate for Payer: Prime Health Services Commercial |
$0.38
|
| Rate for Payer: Riverside University Health System MISP |
$0.18
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.27
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.27
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.23
|
| Rate for Payer: United Healthcare All Other HMO |
$0.23
|
| Rate for Payer: United Healthcare HMO Rider |
$0.23
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.23
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.38
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.38
|
| Rate for Payer: Vantage Medical Group Senior |
$0.38
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE 20 MG TABLET [111424]
|
Facility
|
IP
|
$0.45
|
|
|
Service Code
|
NDC 0185085301
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.41 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Blue Shield of California Commercial |
$0.36
|
| Rate for Payer: Blue Shield of California EPN |
$0.23
|
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: Central Health Plan Commercial |
$0.36
|
| Rate for Payer: Cigna of CA HMO |
$0.32
|
| Rate for Payer: Cigna of CA PPO |
$0.32
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.18
|
| Rate for Payer: EPIC Health Plan Senior |
$0.18
|
| Rate for Payer: Galaxy Health WC |
$0.38
|
| Rate for Payer: Global Benefits Group Commercial |
$0.27
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.41
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.29
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.34
|
| Rate for Payer: Networks By Design Commercial |
$0.29
|
| Rate for Payer: Prime Health Services Commercial |
$0.38
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE 5 MG TABLET [112071]
|
Facility
|
OP
|
$0.24
|
|
|
Service Code
|
NDC 6485050001
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.22 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.15
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.13
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.18
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.12
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.14
|
| Rate for Payer: Blue Shield of California Commercial |
$0.15
|
| Rate for Payer: Blue Shield of California EPN |
$0.10
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Central Health Plan Commercial |
$0.19
|
| Rate for Payer: Cigna of CA HMO |
$0.17
|
| Rate for Payer: Cigna of CA PPO |
$0.17
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.20
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.20
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: EPIC Health Plan Senior |
$0.10
|
| Rate for Payer: Galaxy Health WC |
$0.20
|
| Rate for Payer: Global Benefits Group Commercial |
$0.14
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.22
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.15
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.09
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.18
|
| Rate for Payer: Networks By Design Commercial |
$0.16
|
| Rate for Payer: Prime Health Services Commercial |
$0.20
|
| Rate for Payer: Riverside University Health System MISP |
$0.10
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.14
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.14
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.12
|
| Rate for Payer: United Healthcare All Other HMO |
$0.12
|
| Rate for Payer: United Healthcare HMO Rider |
$0.12
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.12
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.20
|
| Rate for Payer: Vantage Medical Group Senior |
$0.20
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE 5 MG TABLET [112071]
|
Facility
|
IP
|
$0.61
|
|
|
Service Code
|
NDC 0406889101
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.55 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Blue Shield of California Commercial |
$0.49
|
| Rate for Payer: Blue Shield of California EPN |
$0.31
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Central Health Plan Commercial |
$0.49
|
| Rate for Payer: Cigna of CA HMO |
$0.43
|
| Rate for Payer: Cigna of CA PPO |
$0.43
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.24
|
| Rate for Payer: EPIC Health Plan Senior |
$0.24
|
| Rate for Payer: Galaxy Health WC |
$0.52
|
| Rate for Payer: Global Benefits Group Commercial |
$0.37
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.55
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.39
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.46
|
| Rate for Payer: Networks By Design Commercial |
$0.40
|
| Rate for Payer: Prime Health Services Commercial |
$0.52
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE 5 MG TABLET [112071]
|
Facility
|
IP
|
$0.24
|
|
|
Service Code
|
NDC 6485050001
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.22 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Blue Shield of California Commercial |
$0.19
|
| Rate for Payer: Blue Shield of California EPN |
$0.12
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Central Health Plan Commercial |
$0.19
|
| Rate for Payer: Cigna of CA HMO |
$0.17
|
| Rate for Payer: Cigna of CA PPO |
$0.17
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: EPIC Health Plan Senior |
$0.10
|
| Rate for Payer: Galaxy Health WC |
$0.20
|
| Rate for Payer: Global Benefits Group Commercial |
$0.14
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.22
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.15
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.18
|
| Rate for Payer: Networks By Design Commercial |
$0.16
|
| Rate for Payer: Prime Health Services Commercial |
$0.20
|
|
