|
ESTRADIOL 1 MG TABLET [9967]
|
Facility
|
IP
|
$0.10
|
|
|
Service Code
|
NDC 4280608801
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.08
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Central Health Plan Commercial |
$0.08
|
| Rate for Payer: Cigna of CA HMO |
$0.07
|
| Rate for Payer: Cigna of CA PPO |
$0.07
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: EPIC Health Plan Senior |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.09
|
| Rate for Payer: Global Benefits Group Commercial |
$0.06
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.09
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.06
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: Networks By Design Commercial |
$0.07
|
| Rate for Payer: Prime Health Services Commercial |
$0.09
|
|
|
ESTRADIOL 2 MG TABLET [9968]
|
Facility
|
OP
|
$0.17
|
|
|
Service Code
|
NDC 4280608901
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.10
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.13
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.08
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.10
|
| Rate for Payer: Blue Shield of California Commercial |
$0.11
|
| Rate for Payer: Blue Shield of California EPN |
$0.07
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Central Health Plan Commercial |
$0.14
|
| Rate for Payer: Cigna of CA HMO |
$0.12
|
| Rate for Payer: Cigna of CA PPO |
$0.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.14
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.14
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: EPIC Health Plan Senior |
$0.07
|
| Rate for Payer: Galaxy Health WC |
$0.14
|
| Rate for Payer: Global Benefits Group Commercial |
$0.10
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.15
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.11
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.06
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.13
|
| Rate for Payer: Networks By Design Commercial |
$0.11
|
| Rate for Payer: Prime Health Services Commercial |
$0.14
|
| Rate for Payer: Riverside University Health System MISP |
$0.07
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.10
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.10
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.09
|
| Rate for Payer: United Healthcare All Other HMO |
$0.09
|
| Rate for Payer: United Healthcare HMO Rider |
$0.09
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.09
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Vantage Medical Group Senior |
$0.14
|
|
|
ESTRADIOL 2 MG TABLET [9968]
|
Facility
|
OP
|
$0.48
|
|
|
Service Code
|
NDC 0555088702
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.43 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.29
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.41
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.26
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.36
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.23
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.28
|
| Rate for Payer: Blue Shield of California Commercial |
$0.30
|
| Rate for Payer: Blue Shield of California EPN |
$0.19
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Central Health Plan Commercial |
$0.38
|
| Rate for Payer: Cigna of CA HMO |
$0.34
|
| Rate for Payer: Cigna of CA PPO |
$0.34
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.41
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.41
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.41
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| Rate for Payer: EPIC Health Plan Senior |
$0.19
|
| Rate for Payer: Galaxy Health WC |
$0.41
|
| Rate for Payer: Global Benefits Group Commercial |
$0.29
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.43
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.30
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.17
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.34
|
| Rate for Payer: Multiplan Commercial |
$0.36
|
| Rate for Payer: Networks By Design Commercial |
$0.31
|
| Rate for Payer: Prime Health Services Commercial |
$0.41
|
| Rate for Payer: Riverside University Health System MISP |
$0.19
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.29
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.29
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.24
|
| Rate for Payer: United Healthcare All Other HMO |
$0.24
|
| Rate for Payer: United Healthcare HMO Rider |
$0.24
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.24
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.41
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.41
|
| Rate for Payer: Vantage Medical Group Senior |
$0.41
|
|
|
ESTRADIOL 2 MG TABLET [9968]
|
Facility
|
OP
|
$0.48
|
|
|
Service Code
|
NDC 5186233401
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.43 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.29
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.41
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.26
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.36
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.23
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.28
|
| Rate for Payer: Blue Shield of California Commercial |
$0.30
|
| Rate for Payer: Blue Shield of California EPN |
$0.19
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Central Health Plan Commercial |
$0.38
|
| Rate for Payer: Cigna of CA HMO |
$0.34
|
| Rate for Payer: Cigna of CA PPO |
$0.34
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.41
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.41
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.41
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| Rate for Payer: EPIC Health Plan Senior |
$0.19
|
| Rate for Payer: Galaxy Health WC |
$0.41
|
| Rate for Payer: Global Benefits Group Commercial |
$0.29
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.43
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.30
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.17
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.34
|
| Rate for Payer: Multiplan Commercial |
$0.36
|
| Rate for Payer: Networks By Design Commercial |
$0.31
|
| Rate for Payer: Prime Health Services Commercial |
$0.41
|
| Rate for Payer: Riverside University Health System MISP |
$0.19
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.29
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.29
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.24
|
| Rate for Payer: United Healthcare All Other HMO |
$0.24
|
| Rate for Payer: United Healthcare HMO Rider |
$0.24
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.24
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.41
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.41
|
| Rate for Payer: Vantage Medical Group Senior |
$0.41
|
|
|
ESTRADIOL 2 MG TABLET [9968]
|
Facility
|
IP
|
$0.48
|
|
|
Service Code
|
NDC 0555088702
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.43 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Blue Shield of California Commercial |
$0.38
|
| Rate for Payer: Blue Shield of California EPN |
$0.24
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Central Health Plan Commercial |
$0.38
|
| Rate for Payer: Cigna of CA HMO |
$0.34
|
| Rate for Payer: Cigna of CA PPO |
$0.34
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| Rate for Payer: EPIC Health Plan Senior |
$0.19
|
| Rate for Payer: Galaxy Health WC |
$0.41
|
| Rate for Payer: Global Benefits Group Commercial |
$0.29
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.43
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.30
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.36
|
| Rate for Payer: Networks By Design Commercial |
$0.31
|
| Rate for Payer: Prime Health Services Commercial |
$0.41
|
|
|
ESTRADIOL 2 MG TABLET [9968]
|
Facility
|
IP
|
$0.17
|
|
|
Service Code
|
NDC 7095456610
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Blue Shield of California Commercial |
$0.14
|
| Rate for Payer: Blue Shield of California EPN |
$0.09
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Central Health Plan Commercial |
$0.14
|
| Rate for Payer: Cigna of CA HMO |
$0.12
|
| Rate for Payer: Cigna of CA PPO |
$0.12
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: EPIC Health Plan Senior |
$0.07
|
| Rate for Payer: Galaxy Health WC |
$0.14
|
| Rate for Payer: Global Benefits Group Commercial |
$0.10
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.15
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.11
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.13
|
| Rate for Payer: Networks By Design Commercial |
$0.11
|
| Rate for Payer: Prime Health Services Commercial |
$0.14
|
|
|
ESTRADIOL 2 MG TABLET [9968]
|
Facility
|
OP
|
$0.17
|
|
|
Service Code
|
NDC 7095456610
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.10
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.13
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.08
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.10
|
| Rate for Payer: Blue Shield of California Commercial |
$0.11
|
| Rate for Payer: Blue Shield of California EPN |
$0.07
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Central Health Plan Commercial |
$0.14
|
| Rate for Payer: Cigna of CA HMO |
$0.12
|
| Rate for Payer: Cigna of CA PPO |
$0.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.14
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.14
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: EPIC Health Plan Senior |
$0.07
|
| Rate for Payer: Galaxy Health WC |
$0.14
|
| Rate for Payer: Global Benefits Group Commercial |
$0.10
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.15
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.11
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.06
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.13
|
| Rate for Payer: Networks By Design Commercial |
$0.11
|
| Rate for Payer: Prime Health Services Commercial |
$0.14
|
| Rate for Payer: Riverside University Health System MISP |
$0.07
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.10
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.10
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.09
|
| Rate for Payer: United Healthcare All Other HMO |
$0.09
|
| Rate for Payer: United Healthcare HMO Rider |
$0.09
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.09
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Vantage Medical Group Senior |
$0.14
|
|
|
ESTRADIOL 2 MG TABLET [9968]
|
Facility
|
IP
|
$0.48
|
|
|
Service Code
|
NDC 5186233401
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.43 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Blue Shield of California Commercial |
$0.38
|
| Rate for Payer: Blue Shield of California EPN |
$0.24
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Central Health Plan Commercial |
$0.38
|
| Rate for Payer: Cigna of CA HMO |
$0.34
|
| Rate for Payer: Cigna of CA PPO |
$0.34
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| Rate for Payer: EPIC Health Plan Senior |
$0.19
|
| Rate for Payer: Galaxy Health WC |
$0.41
|
| Rate for Payer: Global Benefits Group Commercial |
$0.29
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.43
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.30
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.36
|
| Rate for Payer: Networks By Design Commercial |
$0.31
|
| Rate for Payer: Prime Health Services Commercial |
$0.41
|
|
|
ESTRADIOL 2 MG TABLET [9968]
|
Facility
|
IP
|
$0.17
|
|
|
Service Code
|
NDC 4280608901
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Blue Shield of California Commercial |
$0.14
|
| Rate for Payer: Blue Shield of California EPN |
$0.09
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Central Health Plan Commercial |
$0.14
|
| Rate for Payer: Cigna of CA HMO |
$0.12
|
| Rate for Payer: Cigna of CA PPO |
$0.12
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: EPIC Health Plan Senior |
$0.07
|
| Rate for Payer: Galaxy Health WC |
$0.14
|
| Rate for Payer: Global Benefits Group Commercial |
$0.10
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.15
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.11
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.13
|
| Rate for Payer: Networks By Design Commercial |
$0.11
|
| Rate for Payer: Prime Health Services Commercial |
$0.14
|
|
|
ESZOPICLONE 1 MG TABLET [40320]
|
Facility
|
IP
|
$0.30
|
|
|
Service Code
|
NDC 5511162930
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.27 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California Commercial |
$0.24
|
| Rate for Payer: Blue Shield of California EPN |
$0.15
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Central Health Plan Commercial |
$0.24
|
| Rate for Payer: Cigna of CA HMO |
$0.21
|
| Rate for Payer: Cigna of CA PPO |
$0.21
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: EPIC Health Plan Senior |
$0.12
|
| Rate for Payer: Galaxy Health WC |
$0.26
|
| Rate for Payer: Global Benefits Group Commercial |
$0.18
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.27
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.19
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
| Rate for Payer: Networks By Design Commercial |
$0.20
|
| Rate for Payer: Prime Health Services Commercial |
$0.26
|
|
|
ESZOPICLONE 1 MG TABLET [40320]
|
Facility
|
OP
|
$0.30
|
|
|
Service Code
|
NDC 5511162930
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.27 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.18
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.26
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.17
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.23
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.15
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.17
|
| Rate for Payer: Blue Shield of California Commercial |
$0.19
|
| Rate for Payer: Blue Shield of California EPN |
$0.12
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Central Health Plan Commercial |
$0.24
|
| Rate for Payer: Cigna of CA HMO |
$0.21
|
| Rate for Payer: Cigna of CA PPO |
$0.21
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.26
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.26
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: EPIC Health Plan Senior |
$0.12
|
| Rate for Payer: Galaxy Health WC |
$0.26
|
| Rate for Payer: Global Benefits Group Commercial |
$0.18
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.27
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.19
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.11
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.21
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
| Rate for Payer: Networks By Design Commercial |
$0.20
|
| Rate for Payer: Prime Health Services Commercial |
$0.26
|
| Rate for Payer: Riverside University Health System MISP |
$0.12
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.18
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.18
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.15
|
| Rate for Payer: United Healthcare All Other HMO |
$0.15
|
| Rate for Payer: United Healthcare HMO Rider |
$0.15
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.15
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.26
|
| Rate for Payer: Vantage Medical Group Senior |
$0.26
|
|
|
ETANERCEPT 25 MG/0.5 ML (0.5 ML) SUBCUTANEOUS SYRINGE [108125]
|
Facility
|
IP
|
$2,569.66
|
|
|
Service Code
|
HCPCS J1438
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$513.93 |
| Max. Negotiated Rate |
$2,312.69 |
| Rate for Payer: Adventist Health Commercial |
$513.93
|
| Rate for Payer: Blue Shield of California Commercial |
$2,060.87
|
| Rate for Payer: Blue Shield of California EPN |
$1,295.11
|
| Rate for Payer: Cash Price |
$1,156.35
|
| Rate for Payer: Central Health Plan Commercial |
$2,055.73
|
| Rate for Payer: Cigna of CA HMO |
$1,798.76
|
| Rate for Payer: Cigna of CA PPO |
$1,798.76
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1,798.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,027.86
|
| Rate for Payer: EPIC Health Plan Senior |
$1,027.86
|
| Rate for Payer: Galaxy Health WC |
$2,184.21
|
| Rate for Payer: Global Benefits Group Commercial |
$1,541.80
|
| Rate for Payer: Health Management Network EPO/PPO |
$2,312.69
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1,631.73
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1,516.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$513.93
|
| Rate for Payer: Multiplan Commercial |
$1,927.24
|
| Rate for Payer: Networks By Design Commercial |
$1,284.83
|
| Rate for Payer: Prime Health Services Commercial |
$2,184.21
|
| Rate for Payer: United Healthcare All Other Commercial |
$964.39
|
| Rate for Payer: United Healthcare All Other HMO |
$938.70
|
| Rate for Payer: United Healthcare HMO Rider |
$918.40
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$841.56
|
|
|
ETANERCEPT 25 MG/0.5 ML (0.5 ML) SUBCUTANEOUS SYRINGE [108125]
|
Facility
|
OP
|
$2,569.66
|
|
|
Service Code
|
HCPCS J1438
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$269.38 |
| Max. Negotiated Rate |
$6,231.54 |
| Rate for Payer: Adventist Health Commercial |
$513.93
|
| Rate for Payer: Aetna of CA HMO/PPO |
$6,231.54
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2,184.21
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,413.31
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,927.24
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$269.38
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$336.16
|
| Rate for Payer: Blue Shield of California Commercial |
$1,257.95
|
| Rate for Payer: Blue Shield of California EPN |
$1,143.59
|
| Rate for Payer: Cash Price |
$1,156.35
|
| Rate for Payer: Cash Price |
$1,156.35
|
| Rate for Payer: Central Health Plan Commercial |
$2,055.73
|
| Rate for Payer: Cigna of CA HMO |
$1,798.76
|
| Rate for Payer: Cigna of CA PPO |
$1,798.76
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2,184.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,184.21
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2,184.21
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1,798.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,027.86
|
| Rate for Payer: EPIC Health Plan Senior |
$1,027.86
|
| Rate for Payer: Galaxy Health WC |
$2,184.21
|
| Rate for Payer: Global Benefits Group Commercial |
$1,541.80
|
| Rate for Payer: Health Management Network EPO/PPO |
$2,312.69
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1,631.73
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$932.79
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1,516.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$513.93
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1,798.76
|
| Rate for Payer: Multiplan Commercial |
$1,927.24
|
| Rate for Payer: Networks By Design Commercial |
$1,284.83
|
| Rate for Payer: Prime Health Services Commercial |
$2,184.21
|
| Rate for Payer: Riverside University Health System MISP |
$1,027.86
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1,541.80
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1,541.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$964.39
|
| Rate for Payer: United Healthcare All Other HMO |
$938.70
|
| Rate for Payer: United Healthcare HMO Rider |
$918.40
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$841.56
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2,184.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,184.21
|
| Rate for Payer: Vantage Medical Group Senior |
$2,184.21
|
|
|
ETELCALCETIDE 5 MG/ML INTRAVENOUS SOLUTION [219855]
|
Facility
|
IP
|
$260.14
|
|
|
Service Code
|
HCPCS J0606
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$52.03 |
| Max. Negotiated Rate |
$234.13 |
| Rate for Payer: Adventist Health Commercial |
$52.03
|
| Rate for Payer: Adventist Health Commercial |
$52.03
|
| Rate for Payer: Blue Shield of California Commercial |
$208.63
|
| Rate for Payer: Blue Shield of California Commercial |
$208.62
|
| Rate for Payer: Blue Shield of California EPN |
$131.11
|
| Rate for Payer: Blue Shield of California EPN |
$131.11
|
| Rate for Payer: Cash Price |
$117.06
|
| Rate for Payer: Cash Price |
$117.06
|
| Rate for Payer: Central Health Plan Commercial |
$208.11
|
| Rate for Payer: Central Health Plan Commercial |
$208.10
|
| Rate for Payer: Cigna of CA HMO |
$182.09
|
| Rate for Payer: Cigna of CA HMO |
$182.10
|
| Rate for Payer: Cigna of CA PPO |
$182.09
|
| Rate for Payer: Cigna of CA PPO |
$182.10
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$182.09
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$182.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$104.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$104.06
|
| Rate for Payer: EPIC Health Plan Senior |
$104.05
|
| Rate for Payer: EPIC Health Plan Senior |
$104.06
|
| Rate for Payer: Galaxy Health WC |
$221.12
|
| Rate for Payer: Galaxy Health WC |
$221.11
|
| Rate for Payer: Global Benefits Group Commercial |
$156.08
|
| Rate for Payer: Global Benefits Group Commercial |
$156.08
|
| Rate for Payer: Health Management Network EPO/PPO |
$234.12
|
| Rate for Payer: Health Management Network EPO/PPO |
$234.13
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$165.19
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$165.18
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$153.48
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$153.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$52.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$52.03
|
| Rate for Payer: Multiplan Commercial |
$195.10
|
| Rate for Payer: Multiplan Commercial |
$195.10
|
| Rate for Payer: Networks By Design Commercial |
$130.06
|
| Rate for Payer: Networks By Design Commercial |
$130.07
|
| Rate for Payer: Prime Health Services Commercial |
$221.12
|
| Rate for Payer: Prime Health Services Commercial |
$221.11
|
| Rate for Payer: United Healthcare All Other Commercial |
$97.63
|
| Rate for Payer: United Healthcare All Other Commercial |
$97.63
|
| Rate for Payer: United Healthcare All Other HMO |
$95.03
|
| Rate for Payer: United Healthcare All Other HMO |
$95.03
|
| Rate for Payer: United Healthcare HMO Rider |
$92.97
|
| Rate for Payer: United Healthcare HMO Rider |
$92.97
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$85.19
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$85.20
|
|
|
ETELCALCETIDE 5 MG/ML INTRAVENOUS SOLUTION [219855]
|
Facility
|
OP
|
$260.14
|
|
|
Service Code
|
HCPCS J0606
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.47 |
| Max. Negotiated Rate |
$234.13 |
| Rate for Payer: Adventist Health Commercial |
$52.03
|
| Rate for Payer: Adventist Health Commercial |
$52.03
|
| Rate for Payer: Adventist Health Medi-Cal |
$2.47
|
| Rate for Payer: Adventist Health Medi-Cal |
$2.47
|
| Rate for Payer: Aetna of CA HMO/PPO |
$25.22
|
| Rate for Payer: Aetna of CA HMO/PPO |
$25.22
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.71
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.71
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.72
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.72
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.47
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.47
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$6.41
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$6.41
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8.00
|
| Rate for Payer: Blue Shield of California Commercial |
$5.19
|
| Rate for Payer: Blue Shield of California Commercial |
$5.19
|
| Rate for Payer: Blue Shield of California EPN |
$4.72
|
| Rate for Payer: Blue Shield of California EPN |
$4.72
|
| Rate for Payer: Cash Price |
$117.06
|
| Rate for Payer: Cash Price |
$117.06
|
| Rate for Payer: Cash Price |
$117.06
|
| Rate for Payer: Cash Price |
$117.06
|
| Rate for Payer: Central Health Plan Commercial |
$208.11
|
| Rate for Payer: Central Health Plan Commercial |
$208.10
|
| Rate for Payer: Cigna of CA HMO |
$182.10
|
| Rate for Payer: Cigna of CA HMO |
$182.09
|
| Rate for Payer: Cigna of CA PPO |
$182.10
|
| Rate for Payer: Cigna of CA PPO |
$182.09
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.71
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.71
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.72
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.72
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.47
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.47
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$182.09
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$182.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.08
|
| Rate for Payer: EPIC Health Plan Senior |
$2.72
|
| Rate for Payer: EPIC Health Plan Senior |
$2.72
|
| Rate for Payer: Galaxy Health WC |
$221.11
|
| Rate for Payer: Galaxy Health WC |
$221.12
|
| Rate for Payer: Global Benefits Group Commercial |
$156.08
|
| Rate for Payer: Global Benefits Group Commercial |
$156.08
|
| Rate for Payer: Health Management Network EPO/PPO |
$234.12
|
| Rate for Payer: Health Management Network EPO/PPO |
$234.13
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$4.05
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$4.05
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$7.10
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$7.10
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2.47
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2.47
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$165.18
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$165.19
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$7.85
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$7.85
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$3.46
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$3.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$52.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$52.03
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$3.31
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$3.31
|
| Rate for Payer: Multiplan Commercial |
$195.10
|
| Rate for Payer: Multiplan Commercial |
$195.10
|
| Rate for Payer: Networks By Design Commercial |
$130.06
|
| Rate for Payer: Networks By Design Commercial |
$130.07
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$2.47
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$2.47
|
| Rate for Payer: Prime Health Services Commercial |
$221.11
|
| Rate for Payer: Prime Health Services Commercial |
$221.12
|
| Rate for Payer: Prime Health Services Medicare |
$2.62
|
| Rate for Payer: Prime Health Services Medicare |
$2.62
|
| Rate for Payer: Riverside University Health System MISP |
$2.72
|
| Rate for Payer: Riverside University Health System MISP |
$2.72
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$156.08
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$156.08
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$156.08
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$156.08
|
| Rate for Payer: United Healthcare All Other Commercial |
$97.63
|
| Rate for Payer: United Healthcare All Other Commercial |
$97.63
|
| Rate for Payer: United Healthcare All Other HMO |
$95.03
|
| Rate for Payer: United Healthcare All Other HMO |
$95.03
|
| Rate for Payer: United Healthcare HMO Rider |
$92.97
|
| Rate for Payer: United Healthcare HMO Rider |
$92.97
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$85.20
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$85.19
|
| Rate for Payer: Upland Medical Group Pediatric |
$2.47
|
| Rate for Payer: Upland Medical Group Pediatric |
$2.47
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.71
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.71
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.72
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.72
|
| Rate for Payer: Vantage Medical Group Senior |
$2.47
|
| Rate for Payer: Vantage Medical Group Senior |
$2.47
|
|
|
ETEPLIRSEN 50 MG/ML INTRAVENOUS SOLUTION [215689]
|
Facility
|
OP
|
$960.00
|
|
|
Service Code
|
HCPCS J1428
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$167.43 |
| Max. Negotiated Rate |
$977.79 |
| Rate for Payer: Adventist Health Commercial |
$192.00
|
| Rate for Payer: Adventist Health Medi-Cal |
$167.43
|
| Rate for Payer: Aetna of CA HMO/PPO |
$977.79
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$251.15
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$184.17
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$167.43
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$316.71
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$395.23
|
| Rate for Payer: Blue Shield of California Commercial |
$211.20
|
| Rate for Payer: Blue Shield of California EPN |
$192.00
|
| Rate for Payer: Cash Price |
$432.00
|
| Rate for Payer: Cash Price |
$432.00
|
| Rate for Payer: Central Health Plan Commercial |
$768.00
|
| Rate for Payer: Cigna of CA HMO |
$672.00
|
| Rate for Payer: Cigna of CA PPO |
$672.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$251.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$184.17
|
| Rate for Payer: Dignity Health Medicare Advantage |
$167.43
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$672.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$276.26
|
| Rate for Payer: EPIC Health Plan Senior |
$184.17
|
| Rate for Payer: Galaxy Health WC |
$816.00
|
| Rate for Payer: Global Benefits Group Commercial |
$576.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$864.00
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$274.59
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$282.87
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$167.43
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$609.60
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$312.47
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$234.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$192.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$224.36
|
| Rate for Payer: Multiplan Commercial |
$720.00
|
| Rate for Payer: Networks By Design Commercial |
$480.00
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$167.43
|
| Rate for Payer: Prime Health Services Commercial |
$816.00
|
| Rate for Payer: Prime Health Services Medicare |
$177.48
|
| Rate for Payer: Riverside University Health System MISP |
$184.17
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$576.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$576.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$360.29
|
| Rate for Payer: United Healthcare All Other HMO |
$350.69
|
| Rate for Payer: United Healthcare HMO Rider |
$343.10
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$314.40
|
| Rate for Payer: Upland Medical Group Pediatric |
$167.43
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$251.15
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$184.17
|
| Rate for Payer: Vantage Medical Group Senior |
$167.43
|
|
|
ETEPLIRSEN 50 MG/ML INTRAVENOUS SOLUTION [215689]
|
Facility
|
IP
|
$960.00
|
|
|
Service Code
|
HCPCS J1428
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$192.00 |
| Max. Negotiated Rate |
$864.00 |
| Rate for Payer: Adventist Health Commercial |
$192.00
|
| Rate for Payer: Blue Shield of California Commercial |
$769.92
|
| Rate for Payer: Blue Shield of California EPN |
$483.84
|
| Rate for Payer: Cash Price |
$432.00
|
| Rate for Payer: Central Health Plan Commercial |
$768.00
|
| Rate for Payer: Cigna of CA HMO |
$672.00
|
| Rate for Payer: Cigna of CA PPO |
$672.00
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$672.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$384.00
|
| Rate for Payer: EPIC Health Plan Senior |
$384.00
|
| Rate for Payer: Galaxy Health WC |
$816.00
|
| Rate for Payer: Global Benefits Group Commercial |
$576.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$864.00
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$609.60
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$566.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$192.00
|
| Rate for Payer: Multiplan Commercial |
$720.00
|
| Rate for Payer: Networks By Design Commercial |
$480.00
|
| Rate for Payer: Prime Health Services Commercial |
$816.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$360.29
|
| Rate for Payer: United Healthcare All Other HMO |
$350.69
|
| Rate for Payer: United Healthcare HMO Rider |
$343.10
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$314.40
|
|
|
ETHACRYNIC ACID 25 MG TABLET [9980]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 0832169011
|
| 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 |
$2.41
|
| Rate for Payer: Blue Shield of California EPN |
$1.51
|
| Rate for Payer: Cash Price |
$1.35
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$1.91
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.77
|
| 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
|
|
|
ETHACRYNIC ACID 25 MG TABLET [9980]
|
Facility
|
OP
|
$29.33
|
|
|
Service Code
|
NDC 2501021515
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.87 |
| Max. Negotiated Rate |
$26.40 |
| Rate for Payer: Adventist Health Commercial |
$5.87
|
| Rate for Payer: Aetna of CA HMO/PPO |
$17.81
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$24.93
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$16.13
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$22.00
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$14.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$17.06
|
| Rate for Payer: Blue Shield of California Commercial |
$18.60
|
| Rate for Payer: Blue Shield of California EPN |
$11.70
|
| Rate for Payer: Cash Price |
$13.20
|
| Rate for Payer: Central Health Plan Commercial |
$23.46
|
| Rate for Payer: Cigna of CA HMO |
$20.53
|
| Rate for Payer: Cigna of CA PPO |
$20.53
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$24.93
|
| Rate for Payer: Dignity Health Medi-Cal |
$24.93
|
| Rate for Payer: Dignity Health Medicare Advantage |
$24.93
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$20.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.73
|
| Rate for Payer: EPIC Health Plan Senior |
$11.73
|
| Rate for Payer: Galaxy Health WC |
$24.93
|
| Rate for Payer: Global Benefits Group Commercial |
$17.60
|
| Rate for Payer: Health Management Network EPO/PPO |
$26.40
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$18.62
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$10.65
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$17.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.87
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$20.53
|
| Rate for Payer: Multiplan Commercial |
$22.00
|
| Rate for Payer: Networks By Design Commercial |
$19.06
|
| Rate for Payer: Prime Health Services Commercial |
$24.93
|
| Rate for Payer: Riverside University Health System MISP |
$11.73
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$17.60
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$17.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$14.66
|
| Rate for Payer: United Healthcare All Other HMO |
$14.66
|
| Rate for Payer: United Healthcare HMO Rider |
$14.66
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$14.66
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$24.93
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$24.93
|
| Rate for Payer: Vantage Medical Group Senior |
$24.93
|
|
|
ETHACRYNIC ACID 25 MG TABLET [9980]
|
Facility
|
IP
|
$29.33
|
|
|
Service Code
|
NDC 2501021515
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.87 |
| Max. Negotiated Rate |
$26.40 |
| Rate for Payer: Adventist Health Commercial |
$5.87
|
| Rate for Payer: Blue Shield of California Commercial |
$23.52
|
| Rate for Payer: Blue Shield of California EPN |
$14.78
|
| Rate for Payer: Cash Price |
$13.20
|
| Rate for Payer: Central Health Plan Commercial |
$23.46
|
| Rate for Payer: Cigna of CA HMO |
$20.53
|
| Rate for Payer: Cigna of CA PPO |
$20.53
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$20.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.73
|
| Rate for Payer: EPIC Health Plan Senior |
$11.73
|
| Rate for Payer: Galaxy Health WC |
$24.93
|
| Rate for Payer: Global Benefits Group Commercial |
$17.60
|
| Rate for Payer: Health Management Network EPO/PPO |
$26.40
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$18.62
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$17.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.87
|
| Rate for Payer: Multiplan Commercial |
$22.00
|
| Rate for Payer: Networks By Design Commercial |
$19.06
|
| Rate for Payer: Prime Health Services Commercial |
$24.93
|
|
|
ETHACRYNIC ACID 25 MG TABLET [9980]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 4279940501
|
| 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 |
$1.75
|
| Rate for Payer: Blue Shield of California Commercial |
$1.90
|
| Rate for Payer: Blue Shield of California EPN |
$1.20
|
| Rate for Payer: Cash Price |
$1.35
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$1.91
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.09
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.77
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.60
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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
|
|
|
ETHACRYNIC ACID 25 MG TABLET [9980]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 0832169011
|
| 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 |
$1.75
|
| Rate for Payer: Blue Shield of California Commercial |
$1.90
|
| Rate for Payer: Blue Shield of California EPN |
$1.20
|
| Rate for Payer: Cash Price |
$1.35
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$1.91
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.09
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.77
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.60
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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
|
|
|
ETHACRYNIC ACID 25 MG TABLET [9980]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 4279940501
|
| 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 |
$2.41
|
| Rate for Payer: Blue Shield of California EPN |
$1.51
|
| Rate for Payer: Cash Price |
$1.35
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$1.91
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.77
|
| 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
|
|
|
ETHACRYNIC ACID 25 MG TABLET [9980]
|
Facility
|
OP
|
$1.80
|
|
|
Service Code
|
NDC 5022833410
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$1.62 |
| Rate for Payer: Adventist Health Commercial |
$0.36
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.09
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.53
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.99
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.35
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.87
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.05
|
| Rate for Payer: Blue Shield of California Commercial |
$1.14
|
| Rate for Payer: Blue Shield of California EPN |
$0.72
|
| Rate for Payer: Cash Price |
$0.81
|
| Rate for Payer: Central Health Plan Commercial |
$1.44
|
| Rate for Payer: Cigna of CA HMO |
$1.26
|
| Rate for Payer: Cigna of CA PPO |
$1.26
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.53
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.53
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.53
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.72
|
| Rate for Payer: EPIC Health Plan Senior |
$0.72
|
| Rate for Payer: Galaxy Health WC |
$1.53
|
| Rate for Payer: Global Benefits Group Commercial |
$1.08
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.62
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.14
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.65
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.36
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1.26
|
| Rate for Payer: Multiplan Commercial |
$1.35
|
| Rate for Payer: Networks By Design Commercial |
$1.17
|
| Rate for Payer: Prime Health Services Commercial |
$1.53
|
| Rate for Payer: Riverside University Health System MISP |
$0.72
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.08
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.08
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.90
|
| Rate for Payer: United Healthcare All Other HMO |
$0.90
|
| Rate for Payer: United Healthcare HMO Rider |
$0.90
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.90
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.53
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.53
|
| Rate for Payer: Vantage Medical Group Senior |
$1.53
|
|
|
ETHACRYNIC ACID 25 MG TABLET [9980]
|
Facility
|
IP
|
$1.80
|
|
|
Service Code
|
NDC 5022833410
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$1.62 |
| Rate for Payer: Adventist Health Commercial |
$0.36
|
| Rate for Payer: Blue Shield of California Commercial |
$1.44
|
| Rate for Payer: Blue Shield of California EPN |
$0.91
|
| Rate for Payer: Cash Price |
$0.81
|
| Rate for Payer: Central Health Plan Commercial |
$1.44
|
| Rate for Payer: Cigna of CA HMO |
$1.26
|
| Rate for Payer: Cigna of CA PPO |
$1.26
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.72
|
| Rate for Payer: EPIC Health Plan Senior |
$0.72
|
| Rate for Payer: Galaxy Health WC |
$1.53
|
| Rate for Payer: Global Benefits Group Commercial |
$1.08
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.62
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.14
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.36
|
| Rate for Payer: Multiplan Commercial |
$1.35
|
| Rate for Payer: Networks By Design Commercial |
$1.17
|
| Rate for Payer: Prime Health Services Commercial |
$1.53
|
|
