|
COMPOUNDING VEHICLE SYRUP NO.23 [222005]
|
Facility
|
OP
|
$0.04
|
|
|
Service Code
|
NDC 3172295901
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.03
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.02
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Central Health Plan Commercial |
$0.03
|
| Rate for Payer: Cigna of CA HMO |
$0.03
|
| Rate for Payer: Cigna of CA PPO |
$0.03
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.03
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Senior |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.03
|
| Rate for Payer: Global Benefits Group Commercial |
$0.02
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.04
|
| Rate for Payer: InnovAge PACE Commercial |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.03
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
| Rate for Payer: Networks By Design Commercial |
$0.03
|
| Rate for Payer: Prime Health Services Commercial |
$0.03
|
| Rate for Payer: Riverside University Health System MISP |
$0.02
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.02
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.02
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.02
|
| Rate for Payer: United Healthcare All Other HMO |
$0.02
|
| Rate for Payer: United Healthcare HMO Rider |
$0.02
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Vantage Medical Group Senior |
$0.03
|
|
|
CONJUGATED ESTROGENS 0.3 MG TABLET [9973]
|
Facility
|
OP
|
$8.49
|
|
|
Service Code
|
NDC 0046-1100-81
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.70 |
| Max. Negotiated Rate |
$7.64 |
| Rate for Payer: Adventist Health Commercial |
$1.70
|
| Rate for Payer: Aetna of CA HMO/PPO |
$5.16
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$7.22
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.67
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$6.37
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$4.11
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.99
|
| Rate for Payer: Blue Shield of California Commercial |
$5.19
|
| Rate for Payer: Blue Shield of California EPN |
$3.39
|
| Rate for Payer: Cash Price |
$4.67
|
| Rate for Payer: Central Health Plan Commercial |
$6.79
|
| Rate for Payer: Cigna of CA HMO |
$5.94
|
| Rate for Payer: Cigna of CA PPO |
$5.94
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.22
|
| Rate for Payer: Dignity Health Medicare Advantage |
$7.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.40
|
| Rate for Payer: EPIC Health Plan Senior |
$3.40
|
| Rate for Payer: Galaxy Health WC |
$7.22
|
| Rate for Payer: Global Benefits Group Commercial |
$5.09
|
| Rate for Payer: Health Management Network EPO/PPO |
$7.64
|
| Rate for Payer: InnovAge PACE Commercial |
$4.25
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5.66
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.23
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.70
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5.94
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5.94
|
| Rate for Payer: Multiplan Commercial |
$6.37
|
| Rate for Payer: Networks By Design Commercial |
$5.52
|
| Rate for Payer: Prime Health Services Commercial |
$7.22
|
| Rate for Payer: Riverside University Health System MISP |
$3.40
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$5.09
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$5.09
|
| Rate for Payer: United Healthcare All Other Commercial |
$4.25
|
| Rate for Payer: United Healthcare All Other HMO |
$4.25
|
| Rate for Payer: United Healthcare HMO Rider |
$4.25
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4.25
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.22
|
| Rate for Payer: Vantage Medical Group Senior |
$7.22
|
|
|
CONJUGATED ESTROGENS 0.3 MG TABLET [9973]
|
Facility
|
IP
|
$8.49
|
|
|
Service Code
|
NDC 0046-1100-81
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.70 |
| Max. Negotiated Rate |
$7.64 |
| Rate for Payer: Adventist Health Commercial |
$1.70
|
| Rate for Payer: Blue Shield of California Commercial |
$6.56
|
| Rate for Payer: Blue Shield of California EPN |
$4.28
|
| Rate for Payer: Cash Price |
$4.67
|
| Rate for Payer: Central Health Plan Commercial |
$6.79
|
| Rate for Payer: Cigna of CA HMO |
$5.94
|
| Rate for Payer: Cigna of CA PPO |
$5.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.40
|
| Rate for Payer: EPIC Health Plan Senior |
$3.40
|
| Rate for Payer: Galaxy Health WC |
$7.22
|
| Rate for Payer: Global Benefits Group Commercial |
$5.09
|
| Rate for Payer: Health Management Network EPO/PPO |
$7.64
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5.66
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.23
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.70
|
| Rate for Payer: Multiplan Commercial |
$6.37
|
| Rate for Payer: Networks By Design Commercial |
$5.52
|
| Rate for Payer: Prime Health Services Commercial |
$7.22
|
|
|
CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM [9977]
|
Facility
|
IP
|
$18.43
|
|
|
Service Code
|
NDC 0046-0872-21
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.69 |
| Max. Negotiated Rate |
$16.59 |
| Rate for Payer: Adventist Health Commercial |
$3.69
|
| Rate for Payer: Blue Shield of California Commercial |
$14.25
|
| Rate for Payer: Blue Shield of California EPN |
$9.29
|
| Rate for Payer: Cash Price |
$10.14
|
| Rate for Payer: Central Health Plan Commercial |
$14.74
|
| Rate for Payer: Cigna of CA HMO |
$12.90
|
| Rate for Payer: Cigna of CA PPO |
$12.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.37
|
| Rate for Payer: EPIC Health Plan Senior |
$7.37
|
| Rate for Payer: Galaxy Health WC |
$15.67
|
| Rate for Payer: Global Benefits Group Commercial |
$11.06
|
| Rate for Payer: Health Management Network EPO/PPO |
$16.59
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$12.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.02
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$11.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.69
|
| Rate for Payer: Multiplan Commercial |
$13.82
|
| Rate for Payer: Networks By Design Commercial |
$11.98
|
| Rate for Payer: Prime Health Services Commercial |
$15.67
|
|
|
CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM [9977]
|
Facility
|
OP
|
$18.43
|
|
|
Service Code
|
NDC 0046-0872-21
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.69 |
| Max. Negotiated Rate |
$16.59 |
| Rate for Payer: Adventist Health Commercial |
$3.69
|
| Rate for Payer: Aetna of CA HMO/PPO |
$11.19
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$15.67
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$10.14
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$13.82
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$8.92
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$10.82
|
| Rate for Payer: Blue Shield of California Commercial |
$11.26
|
| Rate for Payer: Blue Shield of California EPN |
$7.35
|
| Rate for Payer: Cash Price |
$10.14
|
| Rate for Payer: Central Health Plan Commercial |
$14.74
|
| Rate for Payer: Cigna of CA HMO |
$12.90
|
| Rate for Payer: Cigna of CA PPO |
$12.90
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$15.67
|
| Rate for Payer: Dignity Health Medi-Cal |
$15.67
|
| Rate for Payer: Dignity Health Medicare Advantage |
$15.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.37
|
| Rate for Payer: EPIC Health Plan Senior |
$7.37
|
| Rate for Payer: Galaxy Health WC |
$15.67
|
| Rate for Payer: Global Benefits Group Commercial |
$11.06
|
| Rate for Payer: Health Management Network EPO/PPO |
$16.59
|
| Rate for Payer: InnovAge PACE Commercial |
$9.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$12.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.02
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$11.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.69
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$12.90
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$12.90
|
| Rate for Payer: Multiplan Commercial |
$13.82
|
| Rate for Payer: Networks By Design Commercial |
$11.98
|
| Rate for Payer: Prime Health Services Commercial |
$15.67
|
| Rate for Payer: Riverside University Health System MISP |
$7.37
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$11.06
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$11.06
|
| Rate for Payer: United Healthcare All Other Commercial |
$9.21
|
| Rate for Payer: United Healthcare All Other HMO |
$9.21
|
| Rate for Payer: United Healthcare HMO Rider |
$9.21
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$9.21
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$15.67
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$15.67
|
| Rate for Payer: Vantage Medical Group Senior |
$15.67
|
|
|
CONJUGATED ESTROGENS 0.625 MG TABLET [9974]
|
Facility
|
OP
|
$8.49
|
|
|
Service Code
|
NDC 0046-1102-81
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.70 |
| Max. Negotiated Rate |
$7.64 |
| Rate for Payer: Adventist Health Commercial |
$1.70
|
| Rate for Payer: Aetna of CA HMO/PPO |
$5.16
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$7.22
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.67
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$6.37
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$4.11
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.99
|
| Rate for Payer: Blue Shield of California Commercial |
$5.19
|
| Rate for Payer: Blue Shield of California EPN |
$3.39
|
| Rate for Payer: Cash Price |
$4.67
|
| Rate for Payer: Central Health Plan Commercial |
$6.79
|
| Rate for Payer: Cigna of CA HMO |
$5.94
|
| Rate for Payer: Cigna of CA PPO |
$5.94
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.22
|
| Rate for Payer: Dignity Health Medicare Advantage |
$7.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.40
|
| Rate for Payer: EPIC Health Plan Senior |
$3.40
|
| Rate for Payer: Galaxy Health WC |
$7.22
|
| Rate for Payer: Global Benefits Group Commercial |
$5.09
|
| Rate for Payer: Health Management Network EPO/PPO |
$7.64
|
| Rate for Payer: InnovAge PACE Commercial |
$4.25
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5.66
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.23
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.70
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5.94
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5.94
|
| Rate for Payer: Multiplan Commercial |
$6.37
|
| Rate for Payer: Networks By Design Commercial |
$5.52
|
| Rate for Payer: Prime Health Services Commercial |
$7.22
|
| Rate for Payer: Riverside University Health System MISP |
$3.40
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$5.09
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$5.09
|
| Rate for Payer: United Healthcare All Other Commercial |
$4.25
|
| Rate for Payer: United Healthcare All Other HMO |
$4.25
|
| Rate for Payer: United Healthcare HMO Rider |
$4.25
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4.25
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.22
|
| Rate for Payer: Vantage Medical Group Senior |
$7.22
|
|
|
CONJUGATED ESTROGENS 0.625 MG TABLET [9974]
|
Facility
|
IP
|
$8.49
|
|
|
Service Code
|
NDC 0046-1102-81
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.70 |
| Max. Negotiated Rate |
$7.64 |
| Rate for Payer: Adventist Health Commercial |
$1.70
|
| Rate for Payer: Blue Shield of California Commercial |
$6.56
|
| Rate for Payer: Blue Shield of California EPN |
$4.28
|
| Rate for Payer: Cash Price |
$4.67
|
| Rate for Payer: Central Health Plan Commercial |
$6.79
|
| Rate for Payer: Cigna of CA HMO |
$5.94
|
| Rate for Payer: Cigna of CA PPO |
$5.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.40
|
| Rate for Payer: EPIC Health Plan Senior |
$3.40
|
| Rate for Payer: Galaxy Health WC |
$7.22
|
| Rate for Payer: Global Benefits Group Commercial |
$5.09
|
| Rate for Payer: Health Management Network EPO/PPO |
$7.64
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5.66
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.23
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.70
|
| Rate for Payer: Multiplan Commercial |
$6.37
|
| Rate for Payer: Networks By Design Commercial |
$5.52
|
| Rate for Payer: Prime Health Services Commercial |
$7.22
|
|
|
CONJUGATED ESTROGENS 25 MG SOLUTION FOR INJECTION [9972]
|
Facility
|
IP
|
$452.26
|
|
|
Service Code
|
HCPCS J1410
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$90.45 |
| Max. Negotiated Rate |
$407.03 |
| Rate for Payer: Adventist Health Commercial |
$90.45
|
| Rate for Payer: Blue Shield of California Commercial |
$349.60
|
| Rate for Payer: Blue Shield of California EPN |
$227.94
|
| Rate for Payer: Cash Price |
$248.74
|
| Rate for Payer: Central Health Plan Commercial |
$361.81
|
| Rate for Payer: Cigna of CA HMO |
$316.58
|
| Rate for Payer: Cigna of CA PPO |
$316.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$180.90
|
| Rate for Payer: EPIC Health Plan Senior |
$180.90
|
| Rate for Payer: Galaxy Health WC |
$384.42
|
| Rate for Payer: Global Benefits Group Commercial |
$271.36
|
| Rate for Payer: Health Management Network EPO/PPO |
$407.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$301.66
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$172.31
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$279.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$90.45
|
| Rate for Payer: Multiplan Commercial |
$339.19
|
| Rate for Payer: Networks By Design Commercial |
$226.13
|
| Rate for Payer: Prime Health Services Commercial |
$384.42
|
| Rate for Payer: United Healthcare All Other Commercial |
$169.73
|
| Rate for Payer: United Healthcare All Other HMO |
$165.21
|
| Rate for Payer: United Healthcare HMO Rider |
$161.64
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$148.12
|
|
|
CONJUGATED ESTROGENS 25 MG SOLUTION FOR INJECTION [9972]
|
Facility
|
OP
|
$452.26
|
|
|
Service Code
|
HCPCS J1410
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$90.45 |
| Max. Negotiated Rate |
$828.77 |
| Rate for Payer: Adventist Health Commercial |
$90.45
|
| Rate for Payer: Adventist Health Medi-Cal |
$390.74
|
| Rate for Payer: Aetna of CA HMO/PPO |
$274.66
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$488.43
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$429.82
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$429.82
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$828.77
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$254.35
|
| Rate for Payer: Blue Shield of California Commercial |
$485.83
|
| Rate for Payer: Blue Shield of California EPN |
$441.66
|
| Rate for Payer: Cash Price |
$248.74
|
| Rate for Payer: Cash Price |
$248.74
|
| Rate for Payer: Central Health Plan Commercial |
$361.81
|
| Rate for Payer: Cigna of CA HMO |
$316.58
|
| Rate for Payer: Cigna of CA PPO |
$316.58
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$488.43
|
| Rate for Payer: Dignity Health Medi-Cal |
$429.82
|
| Rate for Payer: Dignity Health Medicare Advantage |
$429.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$527.50
|
| Rate for Payer: EPIC Health Plan Senior |
$390.74
|
| Rate for Payer: Galaxy Health WC |
$384.42
|
| Rate for Payer: Global Benefits Group Commercial |
$271.36
|
| Rate for Payer: Health Management Network EPO/PPO |
$407.03
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$640.82
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$382.89
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$390.74
|
| Rate for Payer: InnovAge PACE Commercial |
$586.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$301.66
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$736.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$390.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$90.45
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$523.60
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$523.60
|
| Rate for Payer: Multiplan Commercial |
$339.19
|
| Rate for Payer: Networks By Design Commercial |
$226.13
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$390.74
|
| Rate for Payer: Prime Health Services Commercial |
$384.42
|
| Rate for Payer: Prime Health Services Medicare |
$414.19
|
| Rate for Payer: Riverside University Health System MISP |
$429.82
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$271.36
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$271.36
|
| Rate for Payer: United Healthcare All Other Commercial |
$169.73
|
| Rate for Payer: United Healthcare All Other HMO |
$165.21
|
| Rate for Payer: United Healthcare HMO Rider |
$161.64
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$148.12
|
| Rate for Payer: Upland Medical Group Pediatric |
$390.74
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$488.43
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$429.82
|
| Rate for Payer: Vantage Medical Group Senior |
$429.82
|
|
|
COPPER CHLORIDE ORAL SOLUTION (IV FORM) 0.4 MG/ML [4080425]
|
Facility
|
IP
|
$2.60
|
|
|
Service Code
|
NDC 9994-0804-25
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.52 |
| Max. Negotiated Rate |
$2.34 |
| Rate for Payer: Adventist Health Commercial |
$0.52
|
| Rate for Payer: Blue Shield of California Commercial |
$2.01
|
| Rate for Payer: Blue Shield of California EPN |
$1.31
|
| Rate for Payer: Cash Price |
$1.43
|
| Rate for Payer: Central Health Plan Commercial |
$2.08
|
| Rate for Payer: Cigna of CA HMO |
$1.82
|
| Rate for Payer: Cigna of CA PPO |
$1.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.04
|
| Rate for Payer: EPIC Health Plan Senior |
$1.04
|
| Rate for Payer: Galaxy Health WC |
$2.21
|
| Rate for Payer: Global Benefits Group Commercial |
$1.56
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.34
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.99
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.52
|
| Rate for Payer: Multiplan Commercial |
$1.95
|
| Rate for Payer: Networks By Design Commercial |
$1.69
|
| Rate for Payer: Prime Health Services Commercial |
$2.21
|
|
|
COPPER CHLORIDE ORAL SOLUTION (IV FORM) 0.4 MG/ML [4080425]
|
Facility
|
OP
|
$2.60
|
|
|
Service Code
|
NDC 9994-0804-25
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.52 |
| Max. Negotiated Rate |
$2.34 |
| Rate for Payer: Adventist Health Commercial |
$0.52
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.58
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.21
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.43
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.95
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1.26
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.53
|
| Rate for Payer: Blue Shield of California Commercial |
$1.59
|
| Rate for Payer: Blue Shield of California EPN |
$1.04
|
| Rate for Payer: Cash Price |
$1.43
|
| Rate for Payer: Central Health Plan Commercial |
$2.08
|
| Rate for Payer: Cigna of CA HMO |
$1.82
|
| Rate for Payer: Cigna of CA PPO |
$1.82
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.21
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.04
|
| Rate for Payer: EPIC Health Plan Senior |
$1.04
|
| Rate for Payer: Galaxy Health WC |
$2.21
|
| Rate for Payer: Global Benefits Group Commercial |
$1.56
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.34
|
| Rate for Payer: InnovAge PACE Commercial |
$1.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.99
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.52
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.82
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.82
|
| Rate for Payer: Multiplan Commercial |
$1.95
|
| Rate for Payer: Networks By Design Commercial |
$1.69
|
| Rate for Payer: Prime Health Services Commercial |
$2.21
|
| Rate for Payer: Riverside University Health System MISP |
$1.04
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.56
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.56
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.30
|
| Rate for Payer: United Healthcare All Other HMO |
$1.30
|
| Rate for Payer: United Healthcare HMO Rider |
$1.30
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.30
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.21
|
| Rate for Payer: Vantage Medical Group Senior |
$2.21
|
|
|
COPPER GLUCONATE 2 MG TABLET [112194]
|
Facility
|
OP
|
$0.09
|
|
|
Service Code
|
NDC 0536143901
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.05
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.08
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.05
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.07
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.04
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.05
|
| Rate for Payer: Blue Shield of California Commercial |
$0.05
|
| Rate for Payer: Blue Shield of California EPN |
$0.04
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Central Health Plan Commercial |
$0.07
|
| Rate for Payer: Cigna of CA HMO |
$0.06
|
| Rate for Payer: Cigna of CA PPO |
$0.06
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.08
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.08
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: EPIC Health Plan Senior |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.08
|
| Rate for Payer: Global Benefits Group Commercial |
$0.05
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.08
|
| Rate for Payer: InnovAge PACE Commercial |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.06
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.07
|
| Rate for Payer: Networks By Design Commercial |
$0.06
|
| Rate for Payer: Prime Health Services Commercial |
$0.08
|
| Rate for Payer: Riverside University Health System MISP |
$0.04
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.05
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.05
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.05
|
| Rate for Payer: United Healthcare All Other HMO |
$0.05
|
| Rate for Payer: United Healthcare HMO Rider |
$0.05
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.05
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.08
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.08
|
| Rate for Payer: Vantage Medical Group Senior |
$0.08
|
|
|
COPPER GLUCONATE 2 MG TABLET [112194]
|
Facility
|
IP
|
$0.09
|
|
|
Service Code
|
NDC 0536143901
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.07
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Central Health Plan Commercial |
$0.07
|
| Rate for Payer: Cigna of CA HMO |
$0.06
|
| Rate for Payer: Cigna of CA PPO |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: EPIC Health Plan Senior |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.08
|
| Rate for Payer: Global Benefits Group Commercial |
$0.05
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.07
|
| Rate for Payer: Networks By Design Commercial |
$0.06
|
| Rate for Payer: Prime Health Services Commercial |
$0.08
|
|
|
COPPER SULFATE ORAL SOLUTION (IV FORM) 0.4 MG/ML [4080426]
|
Facility
|
IP
|
$0.25
|
|
|
Service Code
|
NDC 9994-0804-26
|
| 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 |
$0.19
|
| Rate for Payer: Blue Shield of California EPN |
$0.13
|
| Rate for Payer: Cash Price |
$0.14
|
| 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: 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 Permanente of CA Commercial/Self Funded |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA 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
|
|
|
COPPER SULFATE ORAL SOLUTION (IV FORM) 0.4 MG/ML [4080426]
|
Facility
|
OP
|
$0.25
|
|
|
Service Code
|
NDC 9994-0804-26
|
| 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 |
$0.15
|
| Rate for Payer: Blue Shield of California EPN |
$0.10
|
| Rate for Payer: Cash Price |
$0.14
|
| 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: 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: InnovAge PACE Commercial |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.18
|
| Rate for Payer: Molina Healthcare of CA 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
|
|
|
COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION [9686]
|
Facility
|
OP
|
$96.24
|
|
|
Service Code
|
HCPCS J0834
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$19.25 |
| Max. Negotiated Rate |
$176.36 |
| Rate for Payer: Adventist Health Commercial |
$19.25
|
| Rate for Payer: Aetna of CA HMO/PPO |
$58.45
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$81.80
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$52.93
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$72.18
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$176.36
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$54.13
|
| Rate for Payer: Blue Shield of California Commercial |
$105.86
|
| Rate for Payer: Blue Shield of California EPN |
$96.24
|
| Rate for Payer: Cash Price |
$52.93
|
| Rate for Payer: Cash Price |
$52.93
|
| Rate for Payer: Central Health Plan Commercial |
$76.99
|
| Rate for Payer: Cigna of CA HMO |
$67.37
|
| Rate for Payer: Cigna of CA PPO |
$67.37
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$81.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$81.80
|
| Rate for Payer: Dignity Health Medicare Advantage |
$81.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$38.50
|
| Rate for Payer: EPIC Health Plan Senior |
$38.50
|
| Rate for Payer: Galaxy Health WC |
$81.80
|
| Rate for Payer: Global Benefits Group Commercial |
$57.74
|
| Rate for Payer: Health Management Network EPO/PPO |
$86.62
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$33.40
|
| Rate for Payer: InnovAge PACE Commercial |
$48.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$64.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$71.99
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$59.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$19.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$67.37
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$67.37
|
| Rate for Payer: Multiplan Commercial |
$72.18
|
| Rate for Payer: Networks By Design Commercial |
$48.12
|
| Rate for Payer: Prime Health Services Commercial |
$81.80
|
| Rate for Payer: Riverside University Health System MISP |
$38.50
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$57.74
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$57.74
|
| Rate for Payer: United Healthcare All Other Commercial |
$36.12
|
| Rate for Payer: United Healthcare All Other HMO |
$35.16
|
| Rate for Payer: United Healthcare HMO Rider |
$34.40
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$31.52
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$81.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$81.80
|
| Rate for Payer: Vantage Medical Group Senior |
$81.80
|
|
|
COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION [9686]
|
Facility
|
IP
|
$96.24
|
|
|
Service Code
|
HCPCS J0834
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$19.25 |
| Max. Negotiated Rate |
$86.62 |
| Rate for Payer: Adventist Health Commercial |
$19.25
|
| Rate for Payer: Blue Shield of California Commercial |
$74.39
|
| Rate for Payer: Blue Shield of California EPN |
$48.50
|
| Rate for Payer: Cash Price |
$52.93
|
| Rate for Payer: Central Health Plan Commercial |
$76.99
|
| Rate for Payer: Cigna of CA HMO |
$67.37
|
| Rate for Payer: Cigna of CA PPO |
$67.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$38.50
|
| Rate for Payer: EPIC Health Plan Senior |
$38.50
|
| Rate for Payer: Galaxy Health WC |
$81.80
|
| Rate for Payer: Global Benefits Group Commercial |
$57.74
|
| Rate for Payer: Health Management Network EPO/PPO |
$86.62
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$64.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$36.67
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$59.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$19.25
|
| Rate for Payer: Multiplan Commercial |
$72.18
|
| Rate for Payer: Networks By Design Commercial |
$48.12
|
| Rate for Payer: Prime Health Services Commercial |
$81.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$36.12
|
| Rate for Payer: United Healthcare All Other HMO |
$35.16
|
| Rate for Payer: United Healthcare HMO Rider |
$34.40
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$31.52
|
|
|
CRIZANLIZUMAB-TMCA 10 MG/ML INTRAVENOUS SOLUTION [225907]
|
Facility
|
OP
|
$294.35
|
|
|
Service Code
|
HCPCS J0791
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$58.87 |
| Max. Negotiated Rate |
$269.71 |
| Rate for Payer: Adventist Health Commercial |
$58.87
|
| Rate for Payer: Adventist Health Medi-Cal |
$129.58
|
| Rate for Payer: Aetna of CA HMO/PPO |
$178.76
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$161.97
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$142.54
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$142.54
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$269.71
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$82.77
|
| Rate for Payer: Blue Shield of California Commercial |
$161.90
|
| Rate for Payer: Blue Shield of California EPN |
$147.18
|
| Rate for Payer: Cash Price |
$161.89
|
| Rate for Payer: Cash Price |
$161.89
|
| Rate for Payer: Central Health Plan Commercial |
$235.48
|
| Rate for Payer: Cigna of CA HMO |
$206.04
|
| Rate for Payer: Cigna of CA PPO |
$206.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$161.97
|
| Rate for Payer: Dignity Health Medi-Cal |
$142.54
|
| Rate for Payer: Dignity Health Medicare Advantage |
$142.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$174.93
|
| Rate for Payer: EPIC Health Plan Senior |
$129.58
|
| Rate for Payer: Galaxy Health WC |
$250.20
|
| Rate for Payer: Global Benefits Group Commercial |
$176.61
|
| Rate for Payer: Health Management Network EPO/PPO |
$264.92
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$212.51
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$129.50
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$129.58
|
| Rate for Payer: InnovAge PACE Commercial |
$194.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$196.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$244.49
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$129.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$58.87
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$173.63
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$173.63
|
| Rate for Payer: Multiplan Commercial |
$220.76
|
| Rate for Payer: Networks By Design Commercial |
$147.18
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$129.58
|
| Rate for Payer: Prime Health Services Commercial |
$250.20
|
| Rate for Payer: Prime Health Services Medicare |
$137.35
|
| Rate for Payer: Riverside University Health System MISP |
$142.54
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$176.61
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$176.61
|
| Rate for Payer: United Healthcare All Other Commercial |
$110.47
|
| Rate for Payer: United Healthcare All Other HMO |
$107.53
|
| Rate for Payer: United Healthcare HMO Rider |
$105.20
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$96.40
|
| Rate for Payer: Upland Medical Group Pediatric |
$129.58
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$161.97
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$142.54
|
| Rate for Payer: Vantage Medical Group Senior |
$142.54
|
|
|
CRIZANLIZUMAB-TMCA 10 MG/ML INTRAVENOUS SOLUTION [225907]
|
Facility
|
IP
|
$294.35
|
|
|
Service Code
|
HCPCS J0791
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$58.87 |
| Max. Negotiated Rate |
$264.92 |
| Rate for Payer: Adventist Health Commercial |
$58.87
|
| Rate for Payer: Blue Shield of California Commercial |
$227.53
|
| Rate for Payer: Blue Shield of California EPN |
$148.35
|
| Rate for Payer: Cash Price |
$161.89
|
| Rate for Payer: Central Health Plan Commercial |
$235.48
|
| Rate for Payer: Cigna of CA HMO |
$206.04
|
| Rate for Payer: Cigna of CA PPO |
$206.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$117.74
|
| Rate for Payer: EPIC Health Plan Senior |
$117.74
|
| Rate for Payer: Galaxy Health WC |
$250.20
|
| Rate for Payer: Global Benefits Group Commercial |
$176.61
|
| Rate for Payer: Health Management Network EPO/PPO |
$264.92
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$196.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$112.15
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$182.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$58.87
|
| Rate for Payer: Multiplan Commercial |
$220.76
|
| Rate for Payer: Networks By Design Commercial |
$147.18
|
| Rate for Payer: Prime Health Services Commercial |
$250.20
|
| Rate for Payer: United Healthcare All Other Commercial |
$110.47
|
| Rate for Payer: United Healthcare All Other HMO |
$107.53
|
| Rate for Payer: United Healthcare HMO Rider |
$105.20
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$96.40
|
|
|
CRIZOTINIB 250 MG CAPSULE [153216]
|
Facility
|
IP
|
$475.46
|
|
|
Service Code
|
NDC 0069-8140-20
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$95.09 |
| Max. Negotiated Rate |
$427.91 |
| Rate for Payer: Adventist Health Commercial |
$95.09
|
| Rate for Payer: Blue Shield of California Commercial |
$367.53
|
| Rate for Payer: Blue Shield of California EPN |
$239.63
|
| Rate for Payer: Cash Price |
$261.50
|
| Rate for Payer: Central Health Plan Commercial |
$380.37
|
| Rate for Payer: Cigna of CA HMO |
$332.82
|
| Rate for Payer: Cigna of CA PPO |
$332.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$190.18
|
| Rate for Payer: EPIC Health Plan Senior |
$190.18
|
| Rate for Payer: Galaxy Health WC |
$404.14
|
| Rate for Payer: Global Benefits Group Commercial |
$285.28
|
| Rate for Payer: Health Management Network EPO/PPO |
$427.91
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$317.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$181.15
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$294.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$95.09
|
| Rate for Payer: Multiplan Commercial |
$356.60
|
| Rate for Payer: Networks By Design Commercial |
$309.05
|
| Rate for Payer: Prime Health Services Commercial |
$404.14
|
|
|
CRIZOTINIB 250 MG CAPSULE [153216]
|
Facility
|
OP
|
$475.46
|
|
|
Service Code
|
NDC 0069-8140-20
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$95.09 |
| Max. Negotiated Rate |
$427.91 |
| Rate for Payer: Adventist Health Commercial |
$95.09
|
| Rate for Payer: Aetna of CA HMO/PPO |
$288.75
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$404.14
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$261.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$356.60
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$230.22
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$279.24
|
| Rate for Payer: Blue Shield of California Commercial |
$290.51
|
| Rate for Payer: Blue Shield of California EPN |
$189.71
|
| Rate for Payer: Cash Price |
$261.50
|
| Rate for Payer: Central Health Plan Commercial |
$380.37
|
| Rate for Payer: Cigna of CA HMO |
$332.82
|
| Rate for Payer: Cigna of CA PPO |
$332.82
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$404.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$404.14
|
| Rate for Payer: Dignity Health Medicare Advantage |
$404.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$190.18
|
| Rate for Payer: EPIC Health Plan Senior |
$190.18
|
| Rate for Payer: Galaxy Health WC |
$404.14
|
| Rate for Payer: Global Benefits Group Commercial |
$285.28
|
| Rate for Payer: Health Management Network EPO/PPO |
$427.91
|
| Rate for Payer: InnovAge PACE Commercial |
$237.73
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$317.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$181.15
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$294.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$95.09
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$332.82
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$332.82
|
| Rate for Payer: Multiplan Commercial |
$356.60
|
| Rate for Payer: Networks By Design Commercial |
$309.05
|
| Rate for Payer: Prime Health Services Commercial |
$404.14
|
| Rate for Payer: Riverside University Health System MISP |
$190.18
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$285.28
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$285.28
|
| Rate for Payer: United Healthcare All Other Commercial |
$237.73
|
| Rate for Payer: United Healthcare All Other HMO |
$237.73
|
| Rate for Payer: United Healthcare HMO Rider |
$237.73
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$237.73
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$404.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$404.14
|
| Rate for Payer: Vantage Medical Group Senior |
$404.14
|
|
|
CROMOLYN 4 % EYE DROPS [9691]
|
Facility
|
OP
|
$2.70
|
|
|
Service Code
|
NDC 61314-237-10
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.54 |
| Max. Negotiated Rate |
$2.43 |
| Rate for Payer: Adventist Health Commercial |
$0.54
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.64
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.29
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.49
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.02
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1.31
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.59
|
| Rate for Payer: Blue Shield of California Commercial |
$1.65
|
| Rate for Payer: Blue Shield of California EPN |
$1.08
|
| Rate for Payer: Cash Price |
$1.49
|
| Rate for Payer: Central Health Plan Commercial |
$2.16
|
| Rate for Payer: Cigna of CA HMO |
$1.89
|
| Rate for Payer: Cigna of CA PPO |
$1.89
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.29
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.29
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.08
|
| Rate for Payer: EPIC Health Plan Senior |
$1.08
|
| Rate for Payer: Galaxy Health WC |
$2.29
|
| Rate for Payer: Global Benefits Group Commercial |
$1.62
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.43
|
| Rate for Payer: InnovAge PACE Commercial |
$1.35
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.03
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.54
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.89
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.89
|
| Rate for Payer: Multiplan Commercial |
$2.02
|
| Rate for Payer: Networks By Design Commercial |
$1.75
|
| Rate for Payer: Prime Health Services Commercial |
$2.29
|
| Rate for Payer: Riverside University Health System MISP |
$1.08
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.62
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.62
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.35
|
| Rate for Payer: United Healthcare All Other HMO |
$1.35
|
| Rate for Payer: United Healthcare HMO Rider |
$1.35
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.35
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.29
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.29
|
| Rate for Payer: Vantage Medical Group Senior |
$2.29
|
|
|
CROMOLYN 4 % EYE DROPS [9691]
|
Facility
|
IP
|
$2.70
|
|
|
Service Code
|
NDC 61314-237-10
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.54 |
| Max. Negotiated Rate |
$2.43 |
| Rate for Payer: Adventist Health Commercial |
$0.54
|
| Rate for Payer: Blue Shield of California Commercial |
$2.09
|
| Rate for Payer: Blue Shield of California EPN |
$1.36
|
| Rate for Payer: Cash Price |
$1.49
|
| Rate for Payer: Central Health Plan Commercial |
$2.16
|
| Rate for Payer: Cigna of CA HMO |
$1.89
|
| Rate for Payer: Cigna of CA PPO |
$1.89
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.08
|
| Rate for Payer: EPIC Health Plan Senior |
$1.08
|
| Rate for Payer: Galaxy Health WC |
$2.29
|
| Rate for Payer: Global Benefits Group Commercial |
$1.62
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.43
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.03
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.54
|
| Rate for Payer: Multiplan Commercial |
$2.02
|
| Rate for Payer: Networks By Design Commercial |
$1.75
|
| Rate for Payer: Prime Health Services Commercial |
$2.29
|
|
|
CUPRIC CHLORIDE 0.4 MG/ML INTRAVENOUS SOLUTION [110358]
|
Facility
|
IP
|
$3.81
|
|
|
Service Code
|
NDC 0409-4092-11
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.76 |
| Max. Negotiated Rate |
$3.43 |
| Rate for Payer: Adventist Health Commercial |
$0.76
|
| Rate for Payer: Blue Shield of California Commercial |
$2.95
|
| Rate for Payer: Blue Shield of California EPN |
$1.92
|
| Rate for Payer: Cash Price |
$2.09
|
| Rate for Payer: Central Health Plan Commercial |
$3.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.52
|
| Rate for Payer: EPIC Health Plan Senior |
$1.52
|
| Rate for Payer: Galaxy Health WC |
$3.24
|
| Rate for Payer: Global Benefits Group Commercial |
$2.29
|
| Rate for Payer: Health Management Network EPO/PPO |
$3.43
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.45
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.76
|
| Rate for Payer: Multiplan Commercial |
$2.86
|
| Rate for Payer: Networks By Design Commercial |
$2.48
|
| Rate for Payer: Prime Health Services Commercial |
$3.24
|
|
|
CUPRIC CHLORIDE 0.4 MG/ML INTRAVENOUS SOLUTION [110358]
|
Facility
|
OP
|
$2.60
|
|
|
Service Code
|
NDC 9994-0804-25
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.52 |
| Max. Negotiated Rate |
$2.34 |
| Rate for Payer: Adventist Health Commercial |
$0.52
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.58
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.21
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.43
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.95
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1.26
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.53
|
| Rate for Payer: Blue Shield of California Commercial |
$1.59
|
| Rate for Payer: Blue Shield of California EPN |
$1.04
|
| Rate for Payer: Cash Price |
$1.43
|
| Rate for Payer: Central Health Plan Commercial |
$2.08
|
| Rate for Payer: Cigna of CA HMO |
$1.66
|
| Rate for Payer: Cigna of CA PPO |
$1.92
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.21
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.04
|
| Rate for Payer: EPIC Health Plan Senior |
$1.04
|
| Rate for Payer: Galaxy Health WC |
$2.21
|
| Rate for Payer: Global Benefits Group Commercial |
$1.56
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.34
|
| Rate for Payer: InnovAge PACE Commercial |
$1.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.99
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.52
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.82
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.82
|
| Rate for Payer: Multiplan Commercial |
$1.95
|
| Rate for Payer: Networks By Design Commercial |
$1.69
|
| Rate for Payer: Prime Health Services Commercial |
$2.21
|
| Rate for Payer: Riverside University Health System MISP |
$1.04
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.56
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.56
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.30
|
| Rate for Payer: United Healthcare All Other HMO |
$1.30
|
| Rate for Payer: United Healthcare HMO Rider |
$1.30
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.30
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.21
|
| Rate for Payer: Vantage Medical Group Senior |
$2.21
|
|
