|
ELECTIVE HIP JOINT REPLACEMENT
|
Facility
|
IP
|
$26,246.90
|
|
|
Service Code
|
APR-DRG 3242
|
| Min. Negotiated Rate |
$16,576.99 |
| Max. Negotiated Rate |
$26,246.90 |
| Rate for Payer: Adventist Health Medi-Cal |
$16,576.99
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$19,754.25
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$26,246.90
|
|
|
ELECTIVE HIP JOINT REPLACEMENT
|
Facility
|
IP
|
$23,380.72
|
|
|
Service Code
|
APR-DRG 3241
|
| Min. Negotiated Rate |
$14,766.77 |
| Max. Negotiated Rate |
$23,380.72 |
| Rate for Payer: Adventist Health Medi-Cal |
$14,766.77
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$17,597.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$23,380.72
|
|
|
ELECTIVE HIP JOINT REPLACEMENT
|
Facility
|
IP
|
$55,694.38
|
|
|
Service Code
|
APR-DRG 3244
|
| Min. Negotiated Rate |
$35,175.40 |
| Max. Negotiated Rate |
$55,694.38 |
| Rate for Payer: Adventist Health Medi-Cal |
$35,175.40
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$41,917.35
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$55,694.38
|
|
|
ELECTIVE KNEE JOINT REPLACEMENT
|
Facility
|
IP
|
$49,263.07
|
|
|
Service Code
|
APR-DRG 3264
|
| Min. Negotiated Rate |
$31,113.52 |
| Max. Negotiated Rate |
$49,263.07 |
| Rate for Payer: Adventist Health Medi-Cal |
$31,113.52
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$37,076.94
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$49,263.07
|
|
|
ELECTIVE KNEE JOINT REPLACEMENT
|
Facility
|
IP
|
$23,191.38
|
|
|
Service Code
|
APR-DRG 3261
|
| Min. Negotiated Rate |
$14,647.19 |
| Max. Negotiated Rate |
$23,191.38 |
| Rate for Payer: Adventist Health Medi-Cal |
$14,647.19
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$17,454.57
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$23,191.38
|
|
|
ELECTIVE KNEE JOINT REPLACEMENT
|
Facility
|
IP
|
$24,625.48
|
|
|
Service Code
|
APR-DRG 3262
|
| Min. Negotiated Rate |
$15,552.94 |
| Max. Negotiated Rate |
$24,625.48 |
| Rate for Payer: Adventist Health Medi-Cal |
$15,552.94
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$18,533.92
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$24,625.48
|
|
|
ELECTIVE KNEE JOINT REPLACEMENT
|
Facility
|
IP
|
$35,355.09
|
|
|
Service Code
|
APR-DRG 3263
|
| Min. Negotiated Rate |
$22,329.53 |
| Max. Negotiated Rate |
$35,355.09 |
| Rate for Payer: Adventist Health Medi-Cal |
$22,329.53
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$26,609.35
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$35,355.09
|
|
|
ELECTROLYTE-A INTRAVENOUS SOLUTION [28113]
|
Facility
|
IP
|
$0.02
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Blue Shield of California Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Central Health Plan Commercial |
$0.02
|
| Rate for Payer: Cigna of CA HMO |
$0.01
|
| Rate for Payer: Cigna of CA PPO |
$0.01
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: EPIC Health Plan Senior |
$0.01
|
| Rate for Payer: Galaxy Health WC |
$0.02
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.02
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: Networks By Design Commercial |
$0.01
|
| Rate for Payer: Prime Health Services Commercial |
$0.02
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.01
|
| Rate for Payer: United Healthcare All Other HMO |
$0.01
|
| Rate for Payer: United Healthcare HMO Rider |
$0.01
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.01
|
|
|
ELECTROLYTE-A INTRAVENOUS SOLUTION [28113]
|
Facility
|
OP
|
$0.02
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Central Health Plan Commercial |
$0.02
|
| Rate for Payer: Cigna of CA HMO |
$0.01
|
| Rate for Payer: Cigna of CA PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.02
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.02
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: EPIC Health Plan Senior |
$0.01
|
| Rate for Payer: Galaxy Health WC |
$0.02
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.02
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: Networks By Design Commercial |
$0.01
|
| Rate for Payer: Prime Health Services Commercial |
$0.02
|
| Rate for Payer: Riverside University Health System MISP |
$0.01
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.01
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.01
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.01
|
| Rate for Payer: United Healthcare All Other HMO |
$0.01
|
| Rate for Payer: United Healthcare HMO Rider |
$0.01
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: Vantage Medical Group Senior |
$0.02
|
|
|
ELECTROLYTE-S INTRAVENOUS SOLUTION [28117]
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Central Health Plan Commercial |
$0.01
|
| Rate for Payer: Cigna of CA HMO |
$0.01
|
| Rate for Payer: Cigna of CA PPO |
$0.01
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.00
|
| Rate for Payer: EPIC Health Plan Senior |
$0.00
|
| Rate for Payer: Galaxy Health WC |
$0.01
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: Networks By Design Commercial |
$0.01
|
| Rate for Payer: Prime Health Services Commercial |
$0.01
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.00
|
| Rate for Payer: United Healthcare All Other HMO |
$0.00
|
| Rate for Payer: United Healthcare HMO Rider |
$0.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.00
|
|
|
ELECTROLYTE-S INTRAVENOUS SOLUTION [28117]
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.00
|
| Rate for Payer: Central Health Plan Commercial |
$0.01
|
| Rate for Payer: Cigna of CA HMO |
$0.01
|
| Rate for Payer: Cigna of CA PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.01
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.01
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.00
|
| Rate for Payer: EPIC Health Plan Senior |
$0.00
|
| Rate for Payer: Galaxy Health WC |
$0.01
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: Networks By Design Commercial |
$0.01
|
| Rate for Payer: Prime Health Services Commercial |
$0.01
|
| Rate for Payer: Riverside University Health System MISP |
$0.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.01
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.01
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.00
|
| Rate for Payer: United Healthcare All Other HMO |
$0.00
|
| Rate for Payer: United Healthcare HMO Rider |
$0.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Vantage Medical Group Senior |
$0.01
|
|
|
ELECTROLYTE-S IV BOLUS [192101]
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.00
|
| Rate for Payer: Central Health Plan Commercial |
$0.01
|
| Rate for Payer: Cigna of CA HMO |
$0.01
|
| Rate for Payer: Cigna of CA PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.01
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.01
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.00
|
| Rate for Payer: EPIC Health Plan Senior |
$0.00
|
| Rate for Payer: Galaxy Health WC |
$0.01
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: Networks By Design Commercial |
$0.01
|
| Rate for Payer: Prime Health Services Commercial |
$0.01
|
| Rate for Payer: Riverside University Health System MISP |
$0.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.01
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.01
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.00
|
| Rate for Payer: United Healthcare All Other HMO |
$0.00
|
| Rate for Payer: United Healthcare HMO Rider |
$0.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Vantage Medical Group Senior |
$0.01
|
|
|
ELECTROLYTE-S IV BOLUS [192101]
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Central Health Plan Commercial |
$0.01
|
| Rate for Payer: Cigna of CA HMO |
$0.01
|
| Rate for Payer: Cigna of CA PPO |
$0.01
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.00
|
| Rate for Payer: EPIC Health Plan Senior |
$0.00
|
| Rate for Payer: Galaxy Health WC |
$0.01
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: Networks By Design Commercial |
$0.01
|
| Rate for Payer: Prime Health Services Commercial |
$0.01
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.00
|
| Rate for Payer: United Healthcare All Other HMO |
$0.00
|
| Rate for Payer: United Healthcare HMO Rider |
$0.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.00
|
|
|
ELECTROLYTE-S (PH 7.4) INTRAVENOUS SOLUTION [28118]
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.00
|
| Rate for Payer: Central Health Plan Commercial |
$0.01
|
| Rate for Payer: Cigna of CA HMO |
$0.01
|
| Rate for Payer: Cigna of CA PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.01
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.01
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.00
|
| Rate for Payer: EPIC Health Plan Senior |
$0.00
|
| Rate for Payer: Galaxy Health WC |
$0.01
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: Networks By Design Commercial |
$0.01
|
| Rate for Payer: Prime Health Services Commercial |
$0.01
|
| Rate for Payer: Riverside University Health System MISP |
$0.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.01
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.01
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.00
|
| Rate for Payer: United Healthcare All Other HMO |
$0.00
|
| Rate for Payer: United Healthcare HMO Rider |
$0.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Vantage Medical Group Senior |
$0.01
|
|
|
ELECTROLYTE-S (PH 7.4) INTRAVENOUS SOLUTION [28118]
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Central Health Plan Commercial |
$0.01
|
| Rate for Payer: Cigna of CA HMO |
$0.01
|
| Rate for Payer: Cigna of CA PPO |
$0.01
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.00
|
| Rate for Payer: EPIC Health Plan Senior |
$0.00
|
| Rate for Payer: Galaxy Health WC |
$0.01
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: Networks By Design Commercial |
$0.01
|
| Rate for Payer: Prime Health Services Commercial |
$0.01
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.00
|
| Rate for Payer: United Healthcare All Other HMO |
$0.00
|
| Rate for Payer: United Healthcare HMO Rider |
$0.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.00
|
|
|
ELETRIPTAN 20 MG TABLET [34683]
|
Facility
|
OP
|
$96.92
|
|
|
Service Code
|
NDC 0049233045
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$19.38 |
| Max. Negotiated Rate |
$87.23 |
| Rate for Payer: Adventist Health Commercial |
$19.38
|
| Rate for Payer: Aetna of CA HMO/PPO |
$58.86
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$82.38
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$53.31
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$72.69
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$46.93
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$56.38
|
| Rate for Payer: Blue Shield of California Commercial |
$61.45
|
| Rate for Payer: Blue Shield of California EPN |
$38.67
|
| Rate for Payer: Cash Price |
$43.61
|
| Rate for Payer: Central Health Plan Commercial |
$77.54
|
| Rate for Payer: Cigna of CA HMO |
$67.84
|
| Rate for Payer: Cigna of CA PPO |
$67.84
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$82.38
|
| Rate for Payer: Dignity Health Medi-Cal |
$82.38
|
| Rate for Payer: Dignity Health Medicare Advantage |
$82.38
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$67.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$38.77
|
| Rate for Payer: EPIC Health Plan Senior |
$38.77
|
| Rate for Payer: Galaxy Health WC |
$82.38
|
| Rate for Payer: Global Benefits Group Commercial |
$58.15
|
| Rate for Payer: Health Management Network EPO/PPO |
$87.23
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$61.54
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$35.18
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$57.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$19.38
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$67.84
|
| Rate for Payer: Multiplan Commercial |
$72.69
|
| Rate for Payer: Networks By Design Commercial |
$63.00
|
| Rate for Payer: Prime Health Services Commercial |
$82.38
|
| Rate for Payer: Riverside University Health System MISP |
$38.77
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$58.15
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$58.15
|
| Rate for Payer: United Healthcare All Other Commercial |
$48.46
|
| Rate for Payer: United Healthcare All Other HMO |
$48.46
|
| Rate for Payer: United Healthcare HMO Rider |
$48.46
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$48.46
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$82.38
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$82.38
|
| Rate for Payer: Vantage Medical Group Senior |
$82.38
|
|
|
ELETRIPTAN 20 MG TABLET [34683]
|
Facility
|
IP
|
$96.92
|
|
|
Service Code
|
NDC 0049233045
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$19.38 |
| Max. Negotiated Rate |
$87.23 |
| Rate for Payer: Adventist Health Commercial |
$19.38
|
| Rate for Payer: Blue Shield of California Commercial |
$77.73
|
| Rate for Payer: Blue Shield of California EPN |
$48.85
|
| Rate for Payer: Cash Price |
$43.61
|
| Rate for Payer: Central Health Plan Commercial |
$77.54
|
| Rate for Payer: Cigna of CA HMO |
$67.84
|
| Rate for Payer: Cigna of CA PPO |
$67.84
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$67.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$38.77
|
| Rate for Payer: EPIC Health Plan Senior |
$38.77
|
| Rate for Payer: Galaxy Health WC |
$82.38
|
| Rate for Payer: Global Benefits Group Commercial |
$58.15
|
| Rate for Payer: Health Management Network EPO/PPO |
$87.23
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$61.54
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$57.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$19.38
|
| Rate for Payer: Multiplan Commercial |
$72.69
|
| Rate for Payer: Networks By Design Commercial |
$63.00
|
| Rate for Payer: Prime Health Services Commercial |
$82.38
|
|
|
ELOTUZUMAB 300 MG INTRAVENOUS SOLUTION [212322]
|
Facility
|
OP
|
$2,841.11
|
|
|
Service Code
|
HCPCS J9176
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.19 |
| Max. Negotiated Rate |
$2,557.00 |
| Rate for Payer: Adventist Health Commercial |
$568.22
|
| Rate for Payer: Adventist Health Medi-Cal |
$8.19
|
| Rate for Payer: Aetna of CA HMO/PPO |
$15.23
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$12.29
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$9.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$8.19
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$11.67
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$14.57
|
| Rate for Payer: Blue Shield of California Commercial |
$9.81
|
| Rate for Payer: Blue Shield of California EPN |
$8.92
|
| Rate for Payer: Cash Price |
$1,278.50
|
| Rate for Payer: Cash Price |
$1,278.50
|
| Rate for Payer: Central Health Plan Commercial |
$2,272.89
|
| Rate for Payer: Cigna of CA HMO |
$1,988.78
|
| Rate for Payer: Cigna of CA PPO |
$1,988.78
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10.24
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.01
|
| Rate for Payer: Dignity Health Medicare Advantage |
$9.01
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1,988.78
|
| Rate for Payer: EPIC Health Plan Commercial |
$13.51
|
| Rate for Payer: EPIC Health Plan Senior |
$9.01
|
| Rate for Payer: Galaxy Health WC |
$2,414.94
|
| Rate for Payer: Global Benefits Group Commercial |
$1,704.67
|
| Rate for Payer: Health Management Network EPO/PPO |
$2,557.00
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$13.43
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$8.19
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$8.19
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1,804.10
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$15.28
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$11.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$568.22
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$10.97
|
| Rate for Payer: Multiplan Commercial |
$2,130.83
|
| Rate for Payer: Networks By Design Commercial |
$1,420.56
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$8.19
|
| Rate for Payer: Prime Health Services Commercial |
$2,414.94
|
| Rate for Payer: Prime Health Services Medicare |
$8.68
|
| Rate for Payer: Riverside University Health System MISP |
$9.01
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1,704.67
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1,704.67
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,066.27
|
| Rate for Payer: United Healthcare All Other HMO |
$1,037.86
|
| Rate for Payer: United Healthcare HMO Rider |
$1,015.41
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$930.46
|
| Rate for Payer: Upland Medical Group Pediatric |
$8.19
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$10.24
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.01
|
| Rate for Payer: Vantage Medical Group Senior |
$9.01
|
|
|
ELOTUZUMAB 300 MG INTRAVENOUS SOLUTION [212322]
|
Facility
|
IP
|
$2,841.11
|
|
|
Service Code
|
HCPCS J9176
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$568.22 |
| Max. Negotiated Rate |
$2,557.00 |
| Rate for Payer: Adventist Health Commercial |
$568.22
|
| Rate for Payer: Blue Shield of California Commercial |
$2,278.57
|
| Rate for Payer: Blue Shield of California EPN |
$1,431.92
|
| Rate for Payer: Cash Price |
$1,278.50
|
| Rate for Payer: Central Health Plan Commercial |
$2,272.89
|
| Rate for Payer: Cigna of CA HMO |
$1,988.78
|
| Rate for Payer: Cigna of CA PPO |
$1,988.78
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1,988.78
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,136.44
|
| Rate for Payer: EPIC Health Plan Senior |
$1,136.44
|
| Rate for Payer: Galaxy Health WC |
$2,414.94
|
| Rate for Payer: Global Benefits Group Commercial |
$1,704.67
|
| Rate for Payer: Health Management Network EPO/PPO |
$2,557.00
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1,804.10
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1,676.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$568.22
|
| Rate for Payer: Multiplan Commercial |
$2,130.83
|
| Rate for Payer: Networks By Design Commercial |
$1,420.56
|
| Rate for Payer: Prime Health Services Commercial |
$2,414.94
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,066.27
|
| Rate for Payer: United Healthcare All Other HMO |
$1,037.86
|
| Rate for Payer: United Healthcare HMO Rider |
$1,015.41
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$930.46
|
|
|
ELOTUZUMAB 400 MG INTRAVENOUS SOLUTION [212323]
|
Facility
|
IP
|
$3,788.11
|
|
|
Service Code
|
HCPCS J9176
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$757.62 |
| Max. Negotiated Rate |
$3,409.30 |
| Rate for Payer: Adventist Health Commercial |
$757.62
|
| Rate for Payer: Blue Shield of California Commercial |
$3,038.06
|
| Rate for Payer: Blue Shield of California EPN |
$1,909.21
|
| Rate for Payer: Cash Price |
$1,704.65
|
| Rate for Payer: Central Health Plan Commercial |
$3,030.49
|
| Rate for Payer: Cigna of CA HMO |
$2,651.68
|
| Rate for Payer: Cigna of CA PPO |
$2,651.68
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$2,651.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,515.24
|
| Rate for Payer: EPIC Health Plan Senior |
$1,515.24
|
| Rate for Payer: Galaxy Health WC |
$3,219.89
|
| Rate for Payer: Global Benefits Group Commercial |
$2,272.87
|
| Rate for Payer: Health Management Network EPO/PPO |
$3,409.30
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$2,405.45
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2,234.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$757.62
|
| Rate for Payer: Multiplan Commercial |
$2,841.08
|
| Rate for Payer: Networks By Design Commercial |
$1,894.06
|
| Rate for Payer: Prime Health Services Commercial |
$3,219.89
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,421.68
|
| Rate for Payer: United Healthcare All Other HMO |
$1,383.80
|
| Rate for Payer: United Healthcare HMO Rider |
$1,353.87
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,240.61
|
|
|
ELOTUZUMAB 400 MG INTRAVENOUS SOLUTION [212323]
|
Facility
|
OP
|
$3,788.11
|
|
|
Service Code
|
HCPCS J9176
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.19 |
| Max. Negotiated Rate |
$3,409.30 |
| Rate for Payer: Adventist Health Commercial |
$757.62
|
| Rate for Payer: Adventist Health Medi-Cal |
$8.19
|
| Rate for Payer: Aetna of CA HMO/PPO |
$15.23
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$12.29
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$9.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$8.19
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$11.67
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$14.57
|
| Rate for Payer: Blue Shield of California Commercial |
$9.81
|
| Rate for Payer: Blue Shield of California EPN |
$8.92
|
| Rate for Payer: Cash Price |
$1,704.65
|
| Rate for Payer: Cash Price |
$1,704.65
|
| Rate for Payer: Central Health Plan Commercial |
$3,030.49
|
| Rate for Payer: Cigna of CA HMO |
$2,651.68
|
| Rate for Payer: Cigna of CA PPO |
$2,651.68
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10.24
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.01
|
| Rate for Payer: Dignity Health Medicare Advantage |
$9.01
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$2,651.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$13.51
|
| Rate for Payer: EPIC Health Plan Senior |
$9.01
|
| Rate for Payer: Galaxy Health WC |
$3,219.89
|
| Rate for Payer: Global Benefits Group Commercial |
$2,272.87
|
| Rate for Payer: Health Management Network EPO/PPO |
$3,409.30
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$13.43
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$8.19
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$8.19
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$2,405.45
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$15.28
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$11.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$757.62
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$10.97
|
| Rate for Payer: Multiplan Commercial |
$2,841.08
|
| Rate for Payer: Networks By Design Commercial |
$1,894.06
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$8.19
|
| Rate for Payer: Prime Health Services Commercial |
$3,219.89
|
| Rate for Payer: Prime Health Services Medicare |
$8.68
|
| Rate for Payer: Riverside University Health System MISP |
$9.01
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2,272.87
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2,272.87
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,421.68
|
| Rate for Payer: United Healthcare All Other HMO |
$1,383.80
|
| Rate for Payer: United Healthcare HMO Rider |
$1,353.87
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,240.61
|
| Rate for Payer: Upland Medical Group Pediatric |
$8.19
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$10.24
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.01
|
| Rate for Payer: Vantage Medical Group Senior |
$9.01
|
|
|
ELRANATAMAB-BCMM 40 MG/ML SUBCUTANEOUS SOLUTION [239200]
|
Facility
|
IP
|
$9,759.06
|
|
|
Service Code
|
HCPCS J1323
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,951.81 |
| Max. Negotiated Rate |
$8,783.15 |
| Rate for Payer: Adventist Health Commercial |
$1,951.81
|
| Rate for Payer: Blue Shield of California Commercial |
$7,826.77
|
| Rate for Payer: Blue Shield of California EPN |
$4,918.57
|
| Rate for Payer: Cash Price |
$4,391.58
|
| Rate for Payer: Central Health Plan Commercial |
$7,807.25
|
| Rate for Payer: Cigna of CA HMO |
$6,831.34
|
| Rate for Payer: Cigna of CA PPO |
$6,831.34
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$6,831.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,903.62
|
| Rate for Payer: EPIC Health Plan Senior |
$3,903.62
|
| Rate for Payer: Galaxy Health WC |
$8,295.20
|
| Rate for Payer: Global Benefits Group Commercial |
$5,855.44
|
| Rate for Payer: Health Management Network EPO/PPO |
$8,783.15
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$6,197.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$5,757.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,951.81
|
| Rate for Payer: Multiplan Commercial |
$7,319.30
|
| Rate for Payer: Networks By Design Commercial |
$4,879.53
|
| Rate for Payer: Prime Health Services Commercial |
$8,295.20
|
| Rate for Payer: United Healthcare All Other Commercial |
$3,662.58
|
| Rate for Payer: United Healthcare All Other HMO |
$3,564.98
|
| Rate for Payer: United Healthcare HMO Rider |
$3,487.89
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3,196.09
|
|
|
ELRANATAMAB-BCMM 40 MG/ML SUBCUTANEOUS SOLUTION [239200]
|
Facility
|
OP
|
$9,759.06
|
|
|
Service Code
|
HCPCS J1323
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$192.48 |
| Max. Negotiated Rate |
$8,783.15 |
| Rate for Payer: Adventist Health Commercial |
$1,951.81
|
| Rate for Payer: Adventist Health Medi-Cal |
$192.48
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1,133.94
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$240.60
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$211.73
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$211.73
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$339.80
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$424.04
|
| Rate for Payer: Blue Shield of California Commercial |
$235.51
|
| Rate for Payer: Blue Shield of California EPN |
$214.10
|
| Rate for Payer: Cash Price |
$4,391.58
|
| Rate for Payer: Cash Price |
$4,391.58
|
| Rate for Payer: Central Health Plan Commercial |
$7,807.25
|
| Rate for Payer: Cigna of CA HMO |
$6,831.34
|
| Rate for Payer: Cigna of CA PPO |
$6,831.34
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$240.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$211.73
|
| Rate for Payer: Dignity Health Medicare Advantage |
$211.73
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$6,831.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$317.59
|
| Rate for Payer: EPIC Health Plan Senior |
$211.73
|
| Rate for Payer: Galaxy Health WC |
$8,295.20
|
| Rate for Payer: Global Benefits Group Commercial |
$5,855.44
|
| Rate for Payer: Health Management Network EPO/PPO |
$8,783.15
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$315.67
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$192.48
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$192.48
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$6,197.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$366.66
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$269.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,951.81
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$257.92
|
| Rate for Payer: Multiplan Commercial |
$7,319.30
|
| Rate for Payer: Networks By Design Commercial |
$4,879.53
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$192.48
|
| Rate for Payer: Prime Health Services Commercial |
$8,295.20
|
| Rate for Payer: Prime Health Services Medicare |
$204.03
|
| Rate for Payer: Riverside University Health System MISP |
$211.73
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$5,855.44
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$5,855.44
|
| Rate for Payer: United Healthcare All Other Commercial |
$3,662.58
|
| Rate for Payer: United Healthcare All Other HMO |
$3,564.98
|
| Rate for Payer: United Healthcare HMO Rider |
$3,487.89
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3,196.09
|
| Rate for Payer: Upland Medical Group Pediatric |
$192.48
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$240.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$211.73
|
| Rate for Payer: Vantage Medical Group Senior |
$211.73
|
|
|
ELTROMBOPAG OLAMINE 25 MG TABLET [94579]
|
Facility
|
OP
|
$313.06
|
|
|
Service Code
|
NDC 0078068515
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$62.61 |
| Max. Negotiated Rate |
$281.75 |
| Rate for Payer: Adventist Health Commercial |
$62.61
|
| Rate for Payer: Aetna of CA HMO/PPO |
$190.12
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$266.10
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$172.18
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$234.79
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$151.58
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$182.11
|
| Rate for Payer: Blue Shield of California Commercial |
$198.48
|
| Rate for Payer: Blue Shield of California EPN |
$124.91
|
| Rate for Payer: Cash Price |
$140.88
|
| Rate for Payer: Central Health Plan Commercial |
$250.45
|
| Rate for Payer: Cigna of CA HMO |
$219.14
|
| Rate for Payer: Cigna of CA PPO |
$219.14
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$266.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$266.10
|
| Rate for Payer: Dignity Health Medicare Advantage |
$266.10
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$219.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$125.22
|
| Rate for Payer: EPIC Health Plan Senior |
$125.22
|
| Rate for Payer: Galaxy Health WC |
$266.10
|
| Rate for Payer: Global Benefits Group Commercial |
$187.84
|
| Rate for Payer: Health Management Network EPO/PPO |
$281.75
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$198.79
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$113.64
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$184.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$62.61
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$219.14
|
| Rate for Payer: Multiplan Commercial |
$234.79
|
| Rate for Payer: Networks By Design Commercial |
$203.49
|
| Rate for Payer: Prime Health Services Commercial |
$266.10
|
| Rate for Payer: Riverside University Health System MISP |
$125.22
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$187.84
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$187.84
|
| Rate for Payer: United Healthcare All Other Commercial |
$156.53
|
| Rate for Payer: United Healthcare All Other HMO |
$156.53
|
| Rate for Payer: United Healthcare HMO Rider |
$156.53
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$156.53
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$266.10
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$266.10
|
| Rate for Payer: Vantage Medical Group Senior |
$266.10
|
|
|
ELTROMBOPAG OLAMINE 25 MG TABLET [94579]
|
Facility
|
IP
|
$313.06
|
|
|
Service Code
|
NDC 0078068515
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$62.61 |
| Max. Negotiated Rate |
$281.75 |
| Rate for Payer: Adventist Health Commercial |
$62.61
|
| Rate for Payer: Blue Shield of California Commercial |
$251.07
|
| Rate for Payer: Blue Shield of California EPN |
$157.78
|
| Rate for Payer: Cash Price |
$140.88
|
| Rate for Payer: Central Health Plan Commercial |
$250.45
|
| Rate for Payer: Cigna of CA HMO |
$219.14
|
| Rate for Payer: Cigna of CA PPO |
$219.14
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$219.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$125.22
|
| Rate for Payer: EPIC Health Plan Senior |
$125.22
|
| Rate for Payer: Galaxy Health WC |
$266.10
|
| Rate for Payer: Global Benefits Group Commercial |
$187.84
|
| Rate for Payer: Health Management Network EPO/PPO |
$281.75
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$198.79
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$184.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$62.61
|
| Rate for Payer: Multiplan Commercial |
$234.79
|
| Rate for Payer: Networks By Design Commercial |
$203.49
|
| Rate for Payer: Prime Health Services Commercial |
$266.10
|
|
