|
CYSTEINE (L-CYSTEINE) 50 MG/ML INTRAVENOUS SOLUTION [4294]
|
Facility
|
IP
|
$11.36
|
|
|
Service Code
|
NDC 51754-1007-1
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.27 |
| Max. Negotiated Rate |
$10.22 |
| Rate for Payer: Adventist Health Commercial |
$2.27
|
| Rate for Payer: Blue Shield of California Commercial |
$8.78
|
| Rate for Payer: Blue Shield of California EPN |
$5.73
|
| Rate for Payer: Cash Price |
$6.25
|
| Rate for Payer: Central Health Plan Commercial |
$9.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.54
|
| Rate for Payer: EPIC Health Plan Senior |
$4.54
|
| Rate for Payer: Galaxy Health WC |
$9.66
|
| Rate for Payer: Global Benefits Group Commercial |
$6.82
|
| Rate for Payer: Health Management Network EPO/PPO |
$10.22
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$7.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.33
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$7.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.27
|
| Rate for Payer: Multiplan Commercial |
$8.52
|
| Rate for Payer: Networks By Design Commercial |
$7.38
|
| Rate for Payer: Prime Health Services Commercial |
$9.66
|
|
|
CYSTEINE (L-CYSTEINE) 50 MG/ML INTRAVENOUS SOLUTION [4294]
|
Facility
|
IP
|
$11.36
|
|
|
Service Code
|
NDC 51754-1007-3
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.27 |
| Max. Negotiated Rate |
$10.22 |
| Rate for Payer: Adventist Health Commercial |
$2.27
|
| Rate for Payer: Blue Shield of California Commercial |
$8.78
|
| Rate for Payer: Blue Shield of California EPN |
$5.73
|
| Rate for Payer: Cash Price |
$6.25
|
| Rate for Payer: Central Health Plan Commercial |
$9.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.54
|
| Rate for Payer: EPIC Health Plan Senior |
$4.54
|
| Rate for Payer: Galaxy Health WC |
$9.66
|
| Rate for Payer: Global Benefits Group Commercial |
$6.82
|
| Rate for Payer: Health Management Network EPO/PPO |
$10.22
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$7.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.33
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$7.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.27
|
| Rate for Payer: Multiplan Commercial |
$8.52
|
| Rate for Payer: Networks By Design Commercial |
$7.38
|
| Rate for Payer: Prime Health Services Commercial |
$9.66
|
|
|
CYSTEINE (L-CYSTEINE) 50 MG/ML INTRAVENOUS SOLUTION [4294]
|
Facility
|
OP
|
$11.36
|
|
|
Service Code
|
NDC 51754-1007-1
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.27 |
| Max. Negotiated Rate |
$10.22 |
| Rate for Payer: Adventist Health Commercial |
$2.27
|
| Rate for Payer: Aetna of CA HMO/PPO |
$6.90
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$9.66
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6.25
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$8.52
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$5.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6.67
|
| Rate for Payer: Blue Shield of California Commercial |
$6.94
|
| Rate for Payer: Blue Shield of California EPN |
$4.53
|
| Rate for Payer: Cash Price |
$6.25
|
| Rate for Payer: Central Health Plan Commercial |
$9.09
|
| Rate for Payer: Cigna of CA HMO |
$7.27
|
| Rate for Payer: Cigna of CA PPO |
$8.41
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.66
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.66
|
| Rate for Payer: Dignity Health Medicare Advantage |
$9.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.54
|
| Rate for Payer: EPIC Health Plan Senior |
$4.54
|
| Rate for Payer: Galaxy Health WC |
$9.66
|
| Rate for Payer: Global Benefits Group Commercial |
$6.82
|
| Rate for Payer: Health Management Network EPO/PPO |
$10.22
|
| Rate for Payer: InnovAge PACE Commercial |
$5.68
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$7.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.33
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$7.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.27
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$7.95
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$7.95
|
| Rate for Payer: Multiplan Commercial |
$8.52
|
| Rate for Payer: Networks By Design Commercial |
$7.38
|
| Rate for Payer: Prime Health Services Commercial |
$9.66
|
| Rate for Payer: Riverside University Health System MISP |
$4.54
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$6.82
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$6.82
|
| Rate for Payer: United Healthcare All Other Commercial |
$5.68
|
| Rate for Payer: United Healthcare All Other HMO |
$5.68
|
| Rate for Payer: United Healthcare HMO Rider |
$5.68
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$5.68
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$9.66
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.66
|
| Rate for Payer: Vantage Medical Group Senior |
$9.66
|
|
|
CYSTEINE (L-CYSTEINE) 50 MG/ML INTRAVENOUS SOLUTION [4294]
|
Facility
|
OP
|
$11.36
|
|
|
Service Code
|
NDC 51754-1007-3
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.27 |
| Max. Negotiated Rate |
$10.22 |
| Rate for Payer: Adventist Health Commercial |
$2.27
|
| Rate for Payer: Aetna of CA HMO/PPO |
$6.90
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$9.66
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6.25
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$8.52
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$5.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6.67
|
| Rate for Payer: Blue Shield of California Commercial |
$6.94
|
| Rate for Payer: Blue Shield of California EPN |
$4.53
|
| Rate for Payer: Cash Price |
$6.25
|
| Rate for Payer: Central Health Plan Commercial |
$9.09
|
| Rate for Payer: Cigna of CA HMO |
$7.27
|
| Rate for Payer: Cigna of CA PPO |
$8.41
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.66
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.66
|
| Rate for Payer: Dignity Health Medicare Advantage |
$9.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.54
|
| Rate for Payer: EPIC Health Plan Senior |
$4.54
|
| Rate for Payer: Galaxy Health WC |
$9.66
|
| Rate for Payer: Global Benefits Group Commercial |
$6.82
|
| Rate for Payer: Health Management Network EPO/PPO |
$10.22
|
| Rate for Payer: InnovAge PACE Commercial |
$5.68
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$7.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.33
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$7.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.27
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$7.95
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$7.95
|
| Rate for Payer: Multiplan Commercial |
$8.52
|
| Rate for Payer: Networks By Design Commercial |
$7.38
|
| Rate for Payer: Prime Health Services Commercial |
$9.66
|
| Rate for Payer: Riverside University Health System MISP |
$4.54
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$6.82
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$6.82
|
| Rate for Payer: United Healthcare All Other Commercial |
$5.68
|
| Rate for Payer: United Healthcare All Other HMO |
$5.68
|
| Rate for Payer: United Healthcare HMO Rider |
$5.68
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$5.68
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$9.66
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.66
|
| Rate for Payer: Vantage Medical Group Senior |
$9.66
|
|
|
CYTARABINE (PF) 2 GRAM/20 ML (100 MG/ML) INJECTION SOLUTION [20156]
|
Facility
|
OP
|
$1.22
|
|
|
Service Code
|
HCPCS J9100
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$9.97 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Adventist Health Commercial |
$0.25
|
| Rate for Payer: Adventist Health Commercial |
$0.22
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.76
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.67
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.74
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.04
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.06
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.94
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.67
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.61
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.69
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.83
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.92
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.94
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$2.13
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$2.13
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$2.13
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.65
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.65
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.65
|
| Rate for Payer: Blue Shield of California Commercial |
$1.28
|
| Rate for Payer: Blue Shield of California Commercial |
$1.28
|
| Rate for Payer: Blue Shield of California Commercial |
$1.28
|
| Rate for Payer: Blue Shield of California EPN |
$1.16
|
| Rate for Payer: Blue Shield of California EPN |
$1.16
|
| Rate for Payer: Blue Shield of California EPN |
$1.16
|
| Rate for Payer: Cash Price |
$0.69
|
| Rate for Payer: Cash Price |
$0.61
|
| Rate for Payer: Cash Price |
$0.61
|
| Rate for Payer: Cash Price |
$0.67
|
| Rate for Payer: Cash Price |
$0.67
|
| Rate for Payer: Cash Price |
$0.69
|
| Rate for Payer: Central Health Plan Commercial |
$1.00
|
| Rate for Payer: Central Health Plan Commercial |
$0.98
|
| Rate for Payer: Central Health Plan Commercial |
$0.88
|
| Rate for Payer: Cigna of CA HMO |
$0.88
|
| Rate for Payer: Cigna of CA HMO |
$0.85
|
| Rate for Payer: Cigna of CA HMO |
$0.77
|
| Rate for Payer: Cigna of CA PPO |
$0.77
|
| Rate for Payer: Cigna of CA PPO |
$0.88
|
| Rate for Payer: Cigna of CA PPO |
$0.85
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.06
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.94
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.94
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.06
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.04
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.94
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.50
|
| Rate for Payer: EPIC Health Plan Senior |
$0.44
|
| Rate for Payer: EPIC Health Plan Senior |
$0.49
|
| Rate for Payer: EPIC Health Plan Senior |
$0.50
|
| Rate for Payer: Galaxy Health WC |
$1.06
|
| Rate for Payer: Galaxy Health WC |
$0.94
|
| Rate for Payer: Galaxy Health WC |
$1.04
|
| Rate for Payer: Global Benefits Group Commercial |
$0.66
|
| Rate for Payer: Global Benefits Group Commercial |
$0.75
|
| Rate for Payer: Global Benefits Group Commercial |
$0.73
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.12
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.99
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.10
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$0.81
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$0.81
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$0.81
|
| Rate for Payer: InnovAge PACE Commercial |
$0.63
|
| Rate for Payer: InnovAge PACE Commercial |
$0.61
|
| Rate for Payer: InnovAge PACE Commercial |
$0.55
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.81
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.73
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.83
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9.97
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.77
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.68
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.88
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.85
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.77
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.77
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.85
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.88
|
| Rate for Payer: Multiplan Commercial |
$0.94
|
| Rate for Payer: Multiplan Commercial |
$0.83
|
| Rate for Payer: Multiplan Commercial |
$0.92
|
| Rate for Payer: Networks By Design Commercial |
$0.55
|
| Rate for Payer: Networks By Design Commercial |
$0.63
|
| Rate for Payer: Networks By Design Commercial |
$0.61
|
| Rate for Payer: Prime Health Services Commercial |
$1.04
|
| Rate for Payer: Prime Health Services Commercial |
$1.06
|
| Rate for Payer: Prime Health Services Commercial |
$0.94
|
| Rate for Payer: Riverside University Health System MISP |
$0.50
|
| Rate for Payer: Riverside University Health System MISP |
$0.49
|
| Rate for Payer: Riverside University Health System MISP |
$0.44
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.73
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.75
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.66
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.73
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.75
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.66
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.47
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.46
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.41
|
| Rate for Payer: United Healthcare All Other HMO |
$0.40
|
| Rate for Payer: United Healthcare All Other HMO |
$0.45
|
| Rate for Payer: United Healthcare All Other HMO |
$0.46
|
| Rate for Payer: United Healthcare HMO Rider |
$0.44
|
| Rate for Payer: United Healthcare HMO Rider |
$0.39
|
| Rate for Payer: United Healthcare HMO Rider |
$0.45
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.41
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.36
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.40
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.94
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.94
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.04
|
| Rate for Payer: Vantage Medical Group Senior |
$1.04
|
| Rate for Payer: Vantage Medical Group Senior |
$0.94
|
| Rate for Payer: Vantage Medical Group Senior |
$1.06
|
|
|
CYTARABINE (PF) 2 GRAM/20 ML (100 MG/ML) INJECTION SOLUTION [20156]
|
Facility
|
IP
|
$1.25
|
|
|
Service Code
|
HCPCS J9100
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$1.12 |
| Rate for Payer: Adventist Health Commercial |
$0.25
|
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Adventist Health Commercial |
$0.22
|
| Rate for Payer: Blue Shield of California Commercial |
$0.97
|
| Rate for Payer: Blue Shield of California Commercial |
$0.94
|
| Rate for Payer: Blue Shield of California Commercial |
$0.85
|
| Rate for Payer: Blue Shield of California EPN |
$0.55
|
| Rate for Payer: Blue Shield of California EPN |
$0.63
|
| Rate for Payer: Blue Shield of California EPN |
$0.61
|
| Rate for Payer: Cash Price |
$0.69
|
| Rate for Payer: Cash Price |
$0.61
|
| Rate for Payer: Cash Price |
$0.67
|
| Rate for Payer: Central Health Plan Commercial |
$0.98
|
| Rate for Payer: Central Health Plan Commercial |
$0.88
|
| Rate for Payer: Central Health Plan Commercial |
$1.00
|
| Rate for Payer: Cigna of CA HMO |
$0.88
|
| Rate for Payer: Cigna of CA HMO |
$0.77
|
| Rate for Payer: Cigna of CA HMO |
$0.85
|
| Rate for Payer: Cigna of CA PPO |
$0.88
|
| Rate for Payer: Cigna of CA PPO |
$0.85
|
| Rate for Payer: Cigna of CA PPO |
$0.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.44
|
| Rate for Payer: EPIC Health Plan Senior |
$0.49
|
| Rate for Payer: EPIC Health Plan Senior |
$0.44
|
| Rate for Payer: EPIC Health Plan Senior |
$0.50
|
| Rate for Payer: Galaxy Health WC |
$1.04
|
| Rate for Payer: Galaxy Health WC |
$0.94
|
| Rate for Payer: Galaxy Health WC |
$1.06
|
| Rate for Payer: Global Benefits Group Commercial |
$0.73
|
| Rate for Payer: Global Benefits Group Commercial |
$0.66
|
| Rate for Payer: Global Benefits Group Commercial |
$0.75
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.12
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.10
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.99
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.83
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.73
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.46
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.77
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.76
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.22
|
| Rate for Payer: Multiplan Commercial |
$0.94
|
| Rate for Payer: Multiplan Commercial |
$0.92
|
| Rate for Payer: Multiplan Commercial |
$0.83
|
| Rate for Payer: Networks By Design Commercial |
$0.63
|
| Rate for Payer: Networks By Design Commercial |
$0.55
|
| Rate for Payer: Networks By Design Commercial |
$0.61
|
| Rate for Payer: Prime Health Services Commercial |
$1.04
|
| Rate for Payer: Prime Health Services Commercial |
$1.06
|
| Rate for Payer: Prime Health Services Commercial |
$0.94
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.41
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.47
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.46
|
| Rate for Payer: United Healthcare All Other HMO |
$0.45
|
| Rate for Payer: United Healthcare All Other HMO |
$0.40
|
| Rate for Payer: United Healthcare All Other HMO |
$0.46
|
| Rate for Payer: United Healthcare HMO Rider |
$0.39
|
| Rate for Payer: United Healthcare HMO Rider |
$0.44
|
| Rate for Payer: United Healthcare HMO Rider |
$0.45
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.40
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.41
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.36
|
|
|
CYTOMEGALOVIRUS IMMUNE GLOBULIN 50 MG/ML INTRAVENOUS SOLUTION [14634]
|
Facility
|
IP
|
$42.16
|
|
|
Service Code
|
HCPCS J0850
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.43 |
| Max. Negotiated Rate |
$37.94 |
| Rate for Payer: Adventist Health Commercial |
$8.43
|
| Rate for Payer: Blue Shield of California Commercial |
$32.59
|
| Rate for Payer: Blue Shield of California EPN |
$21.25
|
| Rate for Payer: Cash Price |
$23.19
|
| Rate for Payer: Central Health Plan Commercial |
$33.73
|
| Rate for Payer: Cigna of CA HMO |
$29.51
|
| Rate for Payer: Cigna of CA PPO |
$29.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$16.86
|
| Rate for Payer: EPIC Health Plan Senior |
$16.86
|
| Rate for Payer: Galaxy Health WC |
$35.84
|
| Rate for Payer: Global Benefits Group Commercial |
$25.30
|
| Rate for Payer: Health Management Network EPO/PPO |
$37.94
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$28.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$16.06
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$26.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.43
|
| Rate for Payer: Multiplan Commercial |
$31.62
|
| Rate for Payer: Networks By Design Commercial |
$21.08
|
| Rate for Payer: Prime Health Services Commercial |
$35.84
|
| Rate for Payer: United Healthcare All Other Commercial |
$15.82
|
| Rate for Payer: United Healthcare All Other HMO |
$15.40
|
| Rate for Payer: United Healthcare HMO Rider |
$15.07
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$13.81
|
|
|
CYTOMEGALOVIRUS IMMUNE GLOBULIN 50 MG/ML INTRAVENOUS SOLUTION [14634]
|
Facility
|
OP
|
$42.16
|
|
|
Service Code
|
HCPCS J0850
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.43 |
| Max. Negotiated Rate |
$3,863.31 |
| Rate for Payer: Adventist Health Commercial |
$8.43
|
| Rate for Payer: Adventist Health Medi-Cal |
$1,809.44
|
| Rate for Payer: Aetna of CA HMO/PPO |
$25.60
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2,261.80
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,990.39
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,990.39
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$3,863.31
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,185.66
|
| Rate for Payer: Blue Shield of California Commercial |
$2,319.04
|
| Rate for Payer: Blue Shield of California EPN |
$2,108.22
|
| Rate for Payer: Cash Price |
$23.19
|
| Rate for Payer: Cash Price |
$23.19
|
| Rate for Payer: Central Health Plan Commercial |
$33.73
|
| Rate for Payer: Cigna of CA HMO |
$29.51
|
| Rate for Payer: Cigna of CA PPO |
$29.51
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2,261.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,990.39
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1,990.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,442.75
|
| Rate for Payer: EPIC Health Plan Senior |
$1,809.44
|
| Rate for Payer: Galaxy Health WC |
$35.84
|
| Rate for Payer: Global Benefits Group Commercial |
$25.30
|
| Rate for Payer: Health Management Network EPO/PPO |
$37.94
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$2,967.49
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$1,812.01
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$1,809.44
|
| Rate for Payer: InnovAge PACE Commercial |
$2,714.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$28.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3,446.81
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,809.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.43
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,424.65
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,424.65
|
| Rate for Payer: Multiplan Commercial |
$31.62
|
| Rate for Payer: Networks By Design Commercial |
$21.08
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$1,809.44
|
| Rate for Payer: Prime Health Services Commercial |
$35.84
|
| Rate for Payer: Prime Health Services Medicare |
$1,918.01
|
| Rate for Payer: Riverside University Health System MISP |
$1,990.39
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$25.30
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$25.30
|
| Rate for Payer: United Healthcare All Other Commercial |
$15.82
|
| Rate for Payer: United Healthcare All Other HMO |
$15.40
|
| Rate for Payer: United Healthcare HMO Rider |
$15.07
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$13.81
|
| Rate for Payer: Upland Medical Group Pediatric |
$1,809.44
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2,261.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,990.39
|
| Rate for Payer: Vantage Medical Group Senior |
$1,990.39
|
|
|
DABIGATRAN ETEXILATE 110 MG CAPSULE [212609]
|
Facility
|
IP
|
$3.97
|
|
|
Service Code
|
NDC 0597-0108-54
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.79 |
| Max. Negotiated Rate |
$3.57 |
| Rate for Payer: Adventist Health Commercial |
$0.79
|
| Rate for Payer: Blue Shield of California Commercial |
$3.07
|
| Rate for Payer: Blue Shield of California EPN |
$2.00
|
| Rate for Payer: Cash Price |
$2.18
|
| Rate for Payer: Central Health Plan Commercial |
$3.18
|
| Rate for Payer: Cigna of CA HMO |
$2.78
|
| Rate for Payer: Cigna of CA PPO |
$2.78
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.59
|
| Rate for Payer: EPIC Health Plan Senior |
$1.59
|
| Rate for Payer: Galaxy Health WC |
$3.37
|
| Rate for Payer: Global Benefits Group Commercial |
$2.38
|
| Rate for Payer: Health Management Network EPO/PPO |
$3.57
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.51
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.79
|
| Rate for Payer: Multiplan Commercial |
$2.98
|
| Rate for Payer: Networks By Design Commercial |
$2.58
|
| Rate for Payer: Prime Health Services Commercial |
$3.37
|
|
|
DABIGATRAN ETEXILATE 110 MG CAPSULE [212609]
|
Facility
|
OP
|
$3.97
|
|
|
Service Code
|
NDC 0597-0108-54
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.79 |
| Max. Negotiated Rate |
$3.57 |
| Rate for Payer: Adventist Health Commercial |
$0.79
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2.41
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.37
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.18
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.98
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1.92
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.33
|
| Rate for Payer: Blue Shield of California Commercial |
$2.43
|
| Rate for Payer: Blue Shield of California EPN |
$1.58
|
| Rate for Payer: Cash Price |
$2.18
|
| Rate for Payer: Central Health Plan Commercial |
$3.18
|
| Rate for Payer: Cigna of CA HMO |
$2.78
|
| Rate for Payer: Cigna of CA PPO |
$2.78
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.37
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.59
|
| Rate for Payer: EPIC Health Plan Senior |
$1.59
|
| Rate for Payer: Galaxy Health WC |
$3.37
|
| Rate for Payer: Global Benefits Group Commercial |
$2.38
|
| Rate for Payer: Health Management Network EPO/PPO |
$3.57
|
| Rate for Payer: InnovAge PACE Commercial |
$1.99
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.51
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.79
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.78
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.78
|
| Rate for Payer: Multiplan Commercial |
$2.98
|
| Rate for Payer: Networks By Design Commercial |
$2.58
|
| Rate for Payer: Prime Health Services Commercial |
$3.37
|
| Rate for Payer: Riverside University Health System MISP |
$1.59
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.38
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.38
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.99
|
| Rate for Payer: United Healthcare All Other HMO |
$1.99
|
| Rate for Payer: United Healthcare HMO Rider |
$1.99
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.99
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.37
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.37
|
| Rate for Payer: Vantage Medical Group Senior |
$3.37
|
|
|
DABIGATRAN ETEXILATE 150 MG CAPSULE [106491]
|
Facility
|
OP
|
$3.97
|
|
|
Service Code
|
NDC 0597-0360-82
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.79 |
| Max. Negotiated Rate |
$3.57 |
| Rate for Payer: Adventist Health Commercial |
$0.79
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2.41
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.37
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.18
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.98
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1.92
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.33
|
| Rate for Payer: Blue Shield of California Commercial |
$2.43
|
| Rate for Payer: Blue Shield of California EPN |
$1.58
|
| Rate for Payer: Cash Price |
$2.18
|
| Rate for Payer: Central Health Plan Commercial |
$3.18
|
| Rate for Payer: Cigna of CA HMO |
$2.78
|
| Rate for Payer: Cigna of CA PPO |
$2.78
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.37
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.59
|
| Rate for Payer: EPIC Health Plan Senior |
$1.59
|
| Rate for Payer: Galaxy Health WC |
$3.37
|
| Rate for Payer: Global Benefits Group Commercial |
$2.38
|
| Rate for Payer: Health Management Network EPO/PPO |
$3.57
|
| Rate for Payer: InnovAge PACE Commercial |
$1.99
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.51
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.79
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.78
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.78
|
| Rate for Payer: Multiplan Commercial |
$2.98
|
| Rate for Payer: Networks By Design Commercial |
$2.58
|
| Rate for Payer: Prime Health Services Commercial |
$3.37
|
| Rate for Payer: Riverside University Health System MISP |
$1.59
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.38
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.38
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.99
|
| Rate for Payer: United Healthcare All Other HMO |
$1.99
|
| Rate for Payer: United Healthcare HMO Rider |
$1.99
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.99
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.37
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.37
|
| Rate for Payer: Vantage Medical Group Senior |
$3.37
|
|
|
DABIGATRAN ETEXILATE 150 MG CAPSULE [106491]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 62332-636-06
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$2.70 |
| Rate for Payer: Adventist Health Commercial |
$0.60
|
| Rate for Payer: Blue Shield of California Commercial |
$2.32
|
| Rate for Payer: Blue Shield of California EPN |
$1.51
|
| Rate for Payer: Cash Price |
$1.65
|
| Rate for Payer: Central Health Plan Commercial |
$2.40
|
| Rate for Payer: Cigna of CA HMO |
$2.10
|
| Rate for Payer: Cigna of CA PPO |
$2.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.20
|
| Rate for Payer: EPIC Health Plan Senior |
$1.20
|
| Rate for Payer: Galaxy Health WC |
$2.55
|
| Rate for Payer: Global Benefits Group Commercial |
$1.80
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.70
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.14
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.60
|
| Rate for Payer: Multiplan Commercial |
$2.25
|
| Rate for Payer: Networks By Design Commercial |
$1.95
|
| Rate for Payer: Prime Health Services Commercial |
$2.55
|
|
|
DABIGATRAN ETEXILATE 150 MG CAPSULE [106491]
|
Facility
|
IP
|
$2.40
|
|
|
Service Code
|
NDC 31722-622-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.48 |
| Max. Negotiated Rate |
$2.16 |
| Rate for Payer: Adventist Health Commercial |
$0.48
|
| Rate for Payer: Blue Shield of California Commercial |
$1.86
|
| Rate for Payer: Blue Shield of California EPN |
$1.21
|
| Rate for Payer: Cash Price |
$1.32
|
| Rate for Payer: Central Health Plan Commercial |
$1.92
|
| Rate for Payer: Cigna of CA HMO |
$1.68
|
| Rate for Payer: Cigna of CA PPO |
$1.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.96
|
| Rate for Payer: EPIC Health Plan Senior |
$0.96
|
| Rate for Payer: Galaxy Health WC |
$2.04
|
| Rate for Payer: Global Benefits Group Commercial |
$1.44
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.16
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.91
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.48
|
| Rate for Payer: Multiplan Commercial |
$1.80
|
| Rate for Payer: Networks By Design Commercial |
$1.56
|
| Rate for Payer: Prime Health Services Commercial |
$2.04
|
|
|
DABIGATRAN ETEXILATE 150 MG CAPSULE [106491]
|
Facility
|
OP
|
$3.97
|
|
|
Service Code
|
NDC 0597-0360-55
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.79 |
| Max. Negotiated Rate |
$3.57 |
| Rate for Payer: Adventist Health Commercial |
$0.79
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2.41
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.37
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.18
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.98
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1.92
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.33
|
| Rate for Payer: Blue Shield of California Commercial |
$2.43
|
| Rate for Payer: Blue Shield of California EPN |
$1.58
|
| Rate for Payer: Cash Price |
$2.18
|
| Rate for Payer: Central Health Plan Commercial |
$3.18
|
| Rate for Payer: Cigna of CA HMO |
$2.78
|
| Rate for Payer: Cigna of CA PPO |
$2.78
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.37
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.59
|
| Rate for Payer: EPIC Health Plan Senior |
$1.59
|
| Rate for Payer: Galaxy Health WC |
$3.37
|
| Rate for Payer: Global Benefits Group Commercial |
$2.38
|
| Rate for Payer: Health Management Network EPO/PPO |
$3.57
|
| Rate for Payer: InnovAge PACE Commercial |
$1.99
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.51
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.79
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.78
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.78
|
| Rate for Payer: Multiplan Commercial |
$2.98
|
| Rate for Payer: Networks By Design Commercial |
$2.58
|
| Rate for Payer: Prime Health Services Commercial |
$3.37
|
| Rate for Payer: Riverside University Health System MISP |
$1.59
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.38
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.38
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.99
|
| Rate for Payer: United Healthcare All Other HMO |
$1.99
|
| Rate for Payer: United Healthcare HMO Rider |
$1.99
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.99
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.37
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.37
|
| Rate for Payer: Vantage Medical Group Senior |
$3.37
|
|
|
DABIGATRAN ETEXILATE 150 MG CAPSULE [106491]
|
Facility
|
OP
|
$2.40
|
|
|
Service Code
|
NDC 31722-622-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.48 |
| Max. Negotiated Rate |
$2.16 |
| Rate for Payer: Adventist Health Commercial |
$0.48
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.46
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.04
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.32
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.80
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1.16
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.41
|
| Rate for Payer: Blue Shield of California Commercial |
$1.47
|
| Rate for Payer: Blue Shield of California EPN |
$0.96
|
| Rate for Payer: Cash Price |
$1.32
|
| Rate for Payer: Central Health Plan Commercial |
$1.92
|
| Rate for Payer: Cigna of CA HMO |
$1.68
|
| Rate for Payer: Cigna of CA PPO |
$1.68
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.04
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.96
|
| Rate for Payer: EPIC Health Plan Senior |
$0.96
|
| Rate for Payer: Galaxy Health WC |
$2.04
|
| Rate for Payer: Global Benefits Group Commercial |
$1.44
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.16
|
| Rate for Payer: InnovAge PACE Commercial |
$1.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.91
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.48
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.68
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.68
|
| Rate for Payer: Multiplan Commercial |
$1.80
|
| Rate for Payer: Networks By Design Commercial |
$1.56
|
| Rate for Payer: Prime Health Services Commercial |
$2.04
|
| Rate for Payer: Riverside University Health System MISP |
$0.96
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.44
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.44
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.20
|
| Rate for Payer: United Healthcare All Other HMO |
$1.20
|
| Rate for Payer: United Healthcare HMO Rider |
$1.20
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.20
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.04
|
| Rate for Payer: Vantage Medical Group Senior |
$2.04
|
|
|
DABIGATRAN ETEXILATE 150 MG CAPSULE [106491]
|
Facility
|
IP
|
$3.97
|
|
|
Service Code
|
NDC 0597-0360-82
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.79 |
| Max. Negotiated Rate |
$3.57 |
| Rate for Payer: Adventist Health Commercial |
$0.79
|
| Rate for Payer: Blue Shield of California Commercial |
$3.07
|
| Rate for Payer: Blue Shield of California EPN |
$2.00
|
| Rate for Payer: Cash Price |
$2.18
|
| Rate for Payer: Central Health Plan Commercial |
$3.18
|
| Rate for Payer: Cigna of CA HMO |
$2.78
|
| Rate for Payer: Cigna of CA PPO |
$2.78
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.59
|
| Rate for Payer: EPIC Health Plan Senior |
$1.59
|
| Rate for Payer: Galaxy Health WC |
$3.37
|
| Rate for Payer: Global Benefits Group Commercial |
$2.38
|
| Rate for Payer: Health Management Network EPO/PPO |
$3.57
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.51
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.79
|
| Rate for Payer: Multiplan Commercial |
$2.98
|
| Rate for Payer: Networks By Design Commercial |
$2.58
|
| Rate for Payer: Prime Health Services Commercial |
$3.37
|
|
|
DABIGATRAN ETEXILATE 150 MG CAPSULE [106491]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 62332-636-06
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$2.70 |
| Rate for Payer: Adventist Health Commercial |
$0.60
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.82
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.55
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.65
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.25
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1.45
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.76
|
| Rate for Payer: Blue Shield of California Commercial |
$1.83
|
| Rate for Payer: Blue Shield of California EPN |
$1.20
|
| Rate for Payer: Cash Price |
$1.65
|
| Rate for Payer: Central Health Plan Commercial |
$2.40
|
| Rate for Payer: Cigna of CA HMO |
$2.10
|
| Rate for Payer: Cigna of CA PPO |
$2.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.55
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.55
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.20
|
| Rate for Payer: EPIC Health Plan Senior |
$1.20
|
| Rate for Payer: Galaxy Health WC |
$2.55
|
| Rate for Payer: Global Benefits Group Commercial |
$1.80
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.70
|
| Rate for Payer: InnovAge PACE Commercial |
$1.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.14
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.60
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.10
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.10
|
| Rate for Payer: Multiplan Commercial |
$2.25
|
| Rate for Payer: Networks By Design Commercial |
$1.95
|
| Rate for Payer: Prime Health Services Commercial |
$2.55
|
| Rate for Payer: Riverside University Health System MISP |
$1.20
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.80
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.50
|
| Rate for Payer: United Healthcare All Other HMO |
$1.50
|
| Rate for Payer: United Healthcare HMO Rider |
$1.50
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.55
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.55
|
| Rate for Payer: Vantage Medical Group Senior |
$2.55
|
|
|
DABIGATRAN ETEXILATE 150 MG CAPSULE [106491]
|
Facility
|
IP
|
$3.97
|
|
|
Service Code
|
NDC 0597-0360-55
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.79 |
| Max. Negotiated Rate |
$3.57 |
| Rate for Payer: Adventist Health Commercial |
$0.79
|
| Rate for Payer: Blue Shield of California Commercial |
$3.07
|
| Rate for Payer: Blue Shield of California EPN |
$2.00
|
| Rate for Payer: Cash Price |
$2.18
|
| Rate for Payer: Central Health Plan Commercial |
$3.18
|
| Rate for Payer: Cigna of CA HMO |
$2.78
|
| Rate for Payer: Cigna of CA PPO |
$2.78
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.59
|
| Rate for Payer: EPIC Health Plan Senior |
$1.59
|
| Rate for Payer: Galaxy Health WC |
$3.37
|
| Rate for Payer: Global Benefits Group Commercial |
$2.38
|
| Rate for Payer: Health Management Network EPO/PPO |
$3.57
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.51
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.79
|
| Rate for Payer: Multiplan Commercial |
$2.98
|
| Rate for Payer: Networks By Design Commercial |
$2.58
|
| Rate for Payer: Prime Health Services Commercial |
$3.37
|
|
|
DABIGATRAN ETEXILATE 75 MG CAPSULE [106490]
|
Facility
|
OP
|
$14.37
|
|
|
Service Code
|
NDC 60687-744-21
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.87 |
| Max. Negotiated Rate |
$12.93 |
| Rate for Payer: Adventist Health Commercial |
$2.87
|
| Rate for Payer: Aetna of CA HMO/PPO |
$8.73
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$12.21
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7.90
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$10.78
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$6.96
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8.44
|
| Rate for Payer: Blue Shield of California Commercial |
$8.78
|
| Rate for Payer: Blue Shield of California EPN |
$5.73
|
| Rate for Payer: Cash Price |
$7.90
|
| Rate for Payer: Central Health Plan Commercial |
$11.50
|
| Rate for Payer: Cigna of CA HMO |
$10.06
|
| Rate for Payer: Cigna of CA PPO |
$10.06
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$12.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$12.21
|
| Rate for Payer: Dignity Health Medicare Advantage |
$12.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.75
|
| Rate for Payer: EPIC Health Plan Senior |
$5.75
|
| Rate for Payer: Galaxy Health WC |
$12.21
|
| Rate for Payer: Global Benefits Group Commercial |
$8.62
|
| Rate for Payer: Health Management Network EPO/PPO |
$12.93
|
| Rate for Payer: InnovAge PACE Commercial |
$7.18
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$9.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.47
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$8.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.87
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$10.06
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$10.06
|
| Rate for Payer: Multiplan Commercial |
$10.78
|
| Rate for Payer: Networks By Design Commercial |
$9.34
|
| Rate for Payer: Prime Health Services Commercial |
$12.21
|
| Rate for Payer: Riverside University Health System MISP |
$5.75
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$8.62
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$8.62
|
| Rate for Payer: United Healthcare All Other Commercial |
$7.18
|
| Rate for Payer: United Healthcare All Other HMO |
$7.18
|
| Rate for Payer: United Healthcare HMO Rider |
$7.18
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$7.18
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$12.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$12.21
|
| Rate for Payer: Vantage Medical Group Senior |
$12.21
|
|
|
DABIGATRAN ETEXILATE 75 MG CAPSULE [106490]
|
Facility
|
IP
|
$3.97
|
|
|
Service Code
|
NDC 0597-0355-56
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.79 |
| Max. Negotiated Rate |
$3.57 |
| Rate for Payer: Adventist Health Commercial |
$0.79
|
| Rate for Payer: Blue Shield of California Commercial |
$3.07
|
| Rate for Payer: Blue Shield of California EPN |
$2.00
|
| Rate for Payer: Cash Price |
$2.18
|
| Rate for Payer: Central Health Plan Commercial |
$3.18
|
| Rate for Payer: Cigna of CA HMO |
$2.78
|
| Rate for Payer: Cigna of CA PPO |
$2.78
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.59
|
| Rate for Payer: EPIC Health Plan Senior |
$1.59
|
| Rate for Payer: Galaxy Health WC |
$3.37
|
| Rate for Payer: Global Benefits Group Commercial |
$2.38
|
| Rate for Payer: Health Management Network EPO/PPO |
$3.57
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.51
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.79
|
| Rate for Payer: Multiplan Commercial |
$2.98
|
| Rate for Payer: Networks By Design Commercial |
$2.58
|
| Rate for Payer: Prime Health Services Commercial |
$3.37
|
|
|
DABIGATRAN ETEXILATE 75 MG CAPSULE [106490]
|
Facility
|
OP
|
$3.97
|
|
|
Service Code
|
NDC 0597-0355-56
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.79 |
| Max. Negotiated Rate |
$3.57 |
| Rate for Payer: Adventist Health Commercial |
$0.79
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2.41
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.37
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.18
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.98
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1.92
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.33
|
| Rate for Payer: Blue Shield of California Commercial |
$2.43
|
| Rate for Payer: Blue Shield of California EPN |
$1.58
|
| Rate for Payer: Cash Price |
$2.18
|
| Rate for Payer: Central Health Plan Commercial |
$3.18
|
| Rate for Payer: Cigna of CA HMO |
$2.78
|
| Rate for Payer: Cigna of CA PPO |
$2.78
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.37
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.59
|
| Rate for Payer: EPIC Health Plan Senior |
$1.59
|
| Rate for Payer: Galaxy Health WC |
$3.37
|
| Rate for Payer: Global Benefits Group Commercial |
$2.38
|
| Rate for Payer: Health Management Network EPO/PPO |
$3.57
|
| Rate for Payer: InnovAge PACE Commercial |
$1.99
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.51
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.79
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.78
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.78
|
| Rate for Payer: Multiplan Commercial |
$2.98
|
| Rate for Payer: Networks By Design Commercial |
$2.58
|
| Rate for Payer: Prime Health Services Commercial |
$3.37
|
| Rate for Payer: Riverside University Health System MISP |
$1.59
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.38
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.38
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.99
|
| Rate for Payer: United Healthcare All Other HMO |
$1.99
|
| Rate for Payer: United Healthcare HMO Rider |
$1.99
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.99
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.37
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.37
|
| Rate for Payer: Vantage Medical Group Senior |
$3.37
|
|
|
DABIGATRAN ETEXILATE 75 MG CAPSULE [106490]
|
Facility
|
OP
|
$14.37
|
|
|
Service Code
|
NDC 60687-744-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.87 |
| Max. Negotiated Rate |
$12.93 |
| Rate for Payer: Adventist Health Commercial |
$2.87
|
| Rate for Payer: Aetna of CA HMO/PPO |
$8.73
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$12.21
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7.90
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$10.78
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$6.96
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8.44
|
| Rate for Payer: Blue Shield of California Commercial |
$8.78
|
| Rate for Payer: Blue Shield of California EPN |
$5.73
|
| Rate for Payer: Cash Price |
$7.90
|
| Rate for Payer: Central Health Plan Commercial |
$11.50
|
| Rate for Payer: Cigna of CA HMO |
$10.06
|
| Rate for Payer: Cigna of CA PPO |
$10.06
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$12.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$12.21
|
| Rate for Payer: Dignity Health Medicare Advantage |
$12.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.75
|
| Rate for Payer: EPIC Health Plan Senior |
$5.75
|
| Rate for Payer: Galaxy Health WC |
$12.21
|
| Rate for Payer: Global Benefits Group Commercial |
$8.62
|
| Rate for Payer: Health Management Network EPO/PPO |
$12.93
|
| Rate for Payer: InnovAge PACE Commercial |
$7.18
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$9.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.47
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$8.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.87
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$10.06
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$10.06
|
| Rate for Payer: Multiplan Commercial |
$10.78
|
| Rate for Payer: Networks By Design Commercial |
$9.34
|
| Rate for Payer: Prime Health Services Commercial |
$12.21
|
| Rate for Payer: Riverside University Health System MISP |
$5.75
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$8.62
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$8.62
|
| Rate for Payer: United Healthcare All Other Commercial |
$7.18
|
| Rate for Payer: United Healthcare All Other HMO |
$7.18
|
| Rate for Payer: United Healthcare HMO Rider |
$7.18
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$7.18
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$12.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$12.21
|
| Rate for Payer: Vantage Medical Group Senior |
$12.21
|
|
|
DABIGATRAN ETEXILATE 75 MG CAPSULE [106490]
|
Facility
|
IP
|
$14.37
|
|
|
Service Code
|
NDC 60687-744-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.87 |
| Max. Negotiated Rate |
$12.93 |
| Rate for Payer: Adventist Health Commercial |
$2.87
|
| Rate for Payer: Blue Shield of California Commercial |
$11.11
|
| Rate for Payer: Blue Shield of California EPN |
$7.24
|
| Rate for Payer: Cash Price |
$7.90
|
| Rate for Payer: Central Health Plan Commercial |
$11.50
|
| Rate for Payer: Cigna of CA HMO |
$10.06
|
| Rate for Payer: Cigna of CA PPO |
$10.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.75
|
| Rate for Payer: EPIC Health Plan Senior |
$5.75
|
| Rate for Payer: Galaxy Health WC |
$12.21
|
| Rate for Payer: Global Benefits Group Commercial |
$8.62
|
| Rate for Payer: Health Management Network EPO/PPO |
$12.93
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$9.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.47
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$8.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.87
|
| Rate for Payer: Multiplan Commercial |
$10.78
|
| Rate for Payer: Networks By Design Commercial |
$9.34
|
| Rate for Payer: Prime Health Services Commercial |
$12.21
|
|
|
DABIGATRAN ETEXILATE 75 MG CAPSULE [106490]
|
Facility
|
IP
|
$14.37
|
|
|
Service Code
|
NDC 60687-744-21
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.87 |
| Max. Negotiated Rate |
$12.93 |
| Rate for Payer: Adventist Health Commercial |
$2.87
|
| Rate for Payer: Blue Shield of California Commercial |
$11.11
|
| Rate for Payer: Blue Shield of California EPN |
$7.24
|
| Rate for Payer: Cash Price |
$7.90
|
| Rate for Payer: Central Health Plan Commercial |
$11.50
|
| Rate for Payer: Cigna of CA HMO |
$10.06
|
| Rate for Payer: Cigna of CA PPO |
$10.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.75
|
| Rate for Payer: EPIC Health Plan Senior |
$5.75
|
| Rate for Payer: Galaxy Health WC |
$12.21
|
| Rate for Payer: Global Benefits Group Commercial |
$8.62
|
| Rate for Payer: Health Management Network EPO/PPO |
$12.93
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$9.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.47
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$8.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.87
|
| Rate for Payer: Multiplan Commercial |
$10.78
|
| Rate for Payer: Networks By Design Commercial |
$9.34
|
| Rate for Payer: Prime Health Services Commercial |
$12.21
|
|
|
DACARBAZINE 100 MG INTRAVENOUS SOLUTION [2090]
|
Facility
|
OP
|
$14.87
|
|
|
Service Code
|
HCPCS J9130
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.97 |
| Max. Negotiated Rate |
$13.38 |
| Rate for Payer: Adventist Health Commercial |
$2.97
|
| Rate for Payer: Aetna of CA HMO/PPO |
$9.03
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$12.64
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8.18
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$11.15
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$13.19
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.05
|
| Rate for Payer: Blue Shield of California Commercial |
$7.92
|
| Rate for Payer: Blue Shield of California EPN |
$7.20
|
| Rate for Payer: Cash Price |
$8.18
|
| Rate for Payer: Cash Price |
$8.18
|
| Rate for Payer: Central Health Plan Commercial |
$11.90
|
| Rate for Payer: Cigna of CA HMO |
$10.41
|
| Rate for Payer: Cigna of CA PPO |
$10.41
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$12.64
|
| Rate for Payer: Dignity Health Medi-Cal |
$12.64
|
| Rate for Payer: Dignity Health Medicare Advantage |
$12.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.95
|
| Rate for Payer: EPIC Health Plan Senior |
$5.95
|
| Rate for Payer: Galaxy Health WC |
$12.64
|
| Rate for Payer: Global Benefits Group Commercial |
$8.92
|
| Rate for Payer: Health Management Network EPO/PPO |
$13.38
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$4.50
|
| Rate for Payer: InnovAge PACE Commercial |
$7.43
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$9.92
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.92
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$9.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.97
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$10.41
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$10.41
|
| Rate for Payer: Multiplan Commercial |
$11.15
|
| Rate for Payer: Networks By Design Commercial |
$7.43
|
| Rate for Payer: Prime Health Services Commercial |
$12.64
|
| Rate for Payer: Riverside University Health System MISP |
$5.95
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$8.92
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$8.92
|
| Rate for Payer: United Healthcare All Other Commercial |
$5.58
|
| Rate for Payer: United Healthcare All Other HMO |
$5.43
|
| Rate for Payer: United Healthcare HMO Rider |
$5.31
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4.87
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$12.64
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$12.64
|
| Rate for Payer: Vantage Medical Group Senior |
$12.64
|
|
