|
ECULIZUMAB 300 MG/30 ML INTRAVENOUS SOLUTION [81696]
|
Facility
|
IP
|
$260.92
|
|
|
Service Code
|
HCPCS J1299
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$52.18 |
| Max. Negotiated Rate |
$234.83 |
| Rate for Payer: Adventist Health Commercial |
$52.18
|
| Rate for Payer: Blue Shield of California Commercial |
$201.69
|
| Rate for Payer: Blue Shield of California EPN |
$131.50
|
| Rate for Payer: Cash Price |
$143.51
|
| Rate for Payer: Central Health Plan Commercial |
$208.74
|
| Rate for Payer: Cigna of CA HMO |
$182.64
|
| Rate for Payer: Cigna of CA PPO |
$182.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$104.37
|
| Rate for Payer: EPIC Health Plan Senior |
$104.37
|
| Rate for Payer: Galaxy Health WC |
$221.78
|
| Rate for Payer: Global Benefits Group Commercial |
$156.55
|
| Rate for Payer: Health Management Network EPO/PPO |
$234.83
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$174.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$99.41
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$161.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$52.18
|
| Rate for Payer: Multiplan Commercial |
$195.69
|
| Rate for Payer: Networks By Design Commercial |
$130.46
|
| Rate for Payer: Prime Health Services Commercial |
$221.78
|
| Rate for Payer: United Healthcare All Other Commercial |
$97.92
|
| Rate for Payer: United Healthcare All Other HMO |
$95.31
|
| Rate for Payer: United Healthcare HMO Rider |
$93.25
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$85.45
|
|
|
EDETATE DISODIUM 3 % EYE DROPS [222529]
|
Facility
|
OP
|
$30.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.00 |
| Max. Negotiated Rate |
$27.00 |
| Rate for Payer: Adventist Health Commercial |
$6.00
|
| Rate for Payer: Aetna of CA HMO/PPO |
$18.22
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$25.50
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$16.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$22.50
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$14.53
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$17.62
|
| Rate for Payer: Blue Shield of California Commercial |
$18.33
|
| Rate for Payer: Blue Shield of California EPN |
$11.97
|
| Rate for Payer: Cash Price |
$16.50
|
| Rate for Payer: Central Health Plan Commercial |
$24.00
|
| Rate for Payer: Cigna of CA HMO |
$21.00
|
| Rate for Payer: Cigna of CA PPO |
$21.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$25.50
|
| Rate for Payer: Dignity Health Medi-Cal |
$25.50
|
| Rate for Payer: Dignity Health Medicare Advantage |
$25.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.00
|
| Rate for Payer: EPIC Health Plan Senior |
$12.00
|
| Rate for Payer: Galaxy Health WC |
$25.50
|
| Rate for Payer: Global Benefits Group Commercial |
$18.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$27.00
|
| Rate for Payer: InnovAge PACE Commercial |
$15.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$20.01
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$18.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$21.00
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$21.00
|
| Rate for Payer: Multiplan Commercial |
$22.50
|
| Rate for Payer: Networks By Design Commercial |
$15.00
|
| Rate for Payer: Prime Health Services Commercial |
$25.50
|
| Rate for Payer: Riverside University Health System MISP |
$12.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$18.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$18.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$11.26
|
| Rate for Payer: United Healthcare All Other HMO |
$10.96
|
| Rate for Payer: United Healthcare HMO Rider |
$10.72
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$9.82
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$25.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$25.50
|
| Rate for Payer: Vantage Medical Group Senior |
$25.50
|
|
|
EDETATE DISODIUM 3 % EYE DROPS [222529]
|
Facility
|
IP
|
$30.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.00 |
| Max. Negotiated Rate |
$27.00 |
| Rate for Payer: Adventist Health Commercial |
$6.00
|
| Rate for Payer: Blue Shield of California Commercial |
$23.19
|
| Rate for Payer: Blue Shield of California EPN |
$15.12
|
| Rate for Payer: Cash Price |
$16.50
|
| Rate for Payer: Central Health Plan Commercial |
$24.00
|
| Rate for Payer: Cigna of CA HMO |
$21.00
|
| Rate for Payer: Cigna of CA PPO |
$21.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.00
|
| Rate for Payer: EPIC Health Plan Senior |
$12.00
|
| Rate for Payer: Galaxy Health WC |
$25.50
|
| Rate for Payer: Global Benefits Group Commercial |
$18.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$27.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$20.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$11.43
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$18.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.00
|
| Rate for Payer: Multiplan Commercial |
$22.50
|
| Rate for Payer: Networks By Design Commercial |
$15.00
|
| Rate for Payer: Prime Health Services Commercial |
$25.50
|
| Rate for Payer: United Healthcare All Other Commercial |
$11.26
|
| Rate for Payer: United Healthcare All Other HMO |
$10.96
|
| Rate for Payer: United Healthcare HMO Rider |
$10.72
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$9.82
|
|
|
EFAVIRENZ 600 MG TABLET [32298]
|
Facility
|
OP
|
$3.20
|
|
|
Service Code
|
NDC 31722-504-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.64 |
| Max. Negotiated Rate |
$2.88 |
| Rate for Payer: Adventist Health Commercial |
$0.64
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.94
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.72
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.76
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.40
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1.55
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.88
|
| Rate for Payer: Blue Shield of California Commercial |
$1.96
|
| Rate for Payer: Blue Shield of California EPN |
$1.28
|
| Rate for Payer: Cash Price |
$1.76
|
| Rate for Payer: Central Health Plan Commercial |
$2.56
|
| Rate for Payer: Cigna of CA HMO |
$2.24
|
| Rate for Payer: Cigna of CA PPO |
$2.24
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.72
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.72
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.28
|
| Rate for Payer: EPIC Health Plan Senior |
$1.28
|
| Rate for Payer: Galaxy Health WC |
$2.72
|
| Rate for Payer: Global Benefits Group Commercial |
$1.92
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.88
|
| Rate for Payer: InnovAge PACE Commercial |
$1.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.22
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.64
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.24
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.24
|
| Rate for Payer: Multiplan Commercial |
$2.40
|
| Rate for Payer: Networks By Design Commercial |
$2.08
|
| Rate for Payer: Prime Health Services Commercial |
$2.72
|
| Rate for Payer: Riverside University Health System MISP |
$1.28
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.92
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.92
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.60
|
| Rate for Payer: United Healthcare All Other HMO |
$1.60
|
| Rate for Payer: United Healthcare HMO Rider |
$1.60
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.60
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.72
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.72
|
| Rate for Payer: Vantage Medical Group Senior |
$2.72
|
|
|
EFAVIRENZ 600 MG TABLET [32298]
|
Facility
|
IP
|
$3.20
|
|
|
Service Code
|
NDC 31722-504-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.64 |
| Max. Negotiated Rate |
$2.88 |
| Rate for Payer: Adventist Health Commercial |
$0.64
|
| Rate for Payer: Blue Shield of California Commercial |
$2.47
|
| Rate for Payer: Blue Shield of California EPN |
$1.61
|
| Rate for Payer: Cash Price |
$1.76
|
| Rate for Payer: Central Health Plan Commercial |
$2.56
|
| Rate for Payer: Cigna of CA HMO |
$2.24
|
| Rate for Payer: Cigna of CA PPO |
$2.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.28
|
| Rate for Payer: EPIC Health Plan Senior |
$1.28
|
| Rate for Payer: Galaxy Health WC |
$2.72
|
| Rate for Payer: Global Benefits Group Commercial |
$1.92
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.88
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.22
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.64
|
| Rate for Payer: Multiplan Commercial |
$2.40
|
| Rate for Payer: Networks By Design Commercial |
$2.08
|
| Rate for Payer: Prime Health Services Commercial |
$2.72
|
|
|
ELECTROLYTE-A INTRAVENOUS SOLUTION [28113]
|
Facility
|
IP
|
$0.02
|
|
|
Service Code
|
NDC 0338-0221-04
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| 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: 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 Permanente of CA Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA 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
|
|
|
ELECTROLYTE-A INTRAVENOUS SOLUTION [28113]
|
Facility
|
OP
|
$0.02
|
|
|
Service Code
|
NDC 0338-0221-04
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| 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: Anthem Blue Cross of CA Exchange |
$0.01
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.01
|
| 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: 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: InnovAge PACE Commercial |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.01
|
| Rate for Payer: Molina Healthcare of CA 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
|
OP
|
$0.01
|
|
|
Service Code
|
NDC 0264-7703-00
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| 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: Anthem Blue Cross of CA Exchange |
$0.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$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: Cash Price |
$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: 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: 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: InnovAge PACE Commercial |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.01
|
| Rate for Payer: Molina Healthcare of CA 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 |
$0.01
|
| 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 |
$0.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Vantage Medical Group Senior |
$0.01
|
|
|
ELECTROLYTE-S INTRAVENOUS SOLUTION [28117]
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
NDC 0264-7703-00
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| 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: Cash Price |
$0.01
|
| Rate for Payer: Central Health Plan Commercial |
$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 Permanente of CA Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: Kaiser Permanente of CA 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
|
|
|
ELECTROLYTE-S IV BOLUS [192101]
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
NDC 0264-7703-00
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| 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: Anthem Blue Cross of CA Exchange |
$0.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$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: Cash Price |
$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: 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: 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: InnovAge PACE Commercial |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.01
|
| Rate for Payer: Molina Healthcare of CA 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 |
$0.01
|
| 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 |
$0.01
|
| 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
|
NDC 0264-7703-00
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| 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: Cash Price |
$0.01
|
| Rate for Payer: Central Health Plan Commercial |
$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 Permanente of CA Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: Kaiser Permanente of CA 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
|
|
|
ELECTROLYTE-S (PH 7.4) INTRAVENOUS SOLUTION [28118]
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
NDC 0264-7707-00
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| 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: 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 Permanente of CA Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: Kaiser Permanente of CA 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
|
|
|
ELECTROLYTE-S (PH 7.4) INTRAVENOUS SOLUTION [28118]
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
NDC 0264-7707-00
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| 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: Anthem Blue Cross of CA Exchange |
$0.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$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: 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: InnovAge PACE Commercial |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.01
|
| Rate for Payer: Molina Healthcare of CA 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 |
$0.01
|
| 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 |
$0.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Vantage Medical Group Senior |
$0.01
|
|
|
ELETRIPTAN 20 MG TABLET [34683]
|
Facility
|
IP
|
$96.92
|
|
|
Service Code
|
NDC 0049-2330-45
|
| 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 |
$74.92
|
| Rate for Payer: Blue Shield of California EPN |
$48.85
|
| Rate for Payer: Cash Price |
$53.31
|
| 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: 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 Permanente of CA Commercial/Self Funded |
$64.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$36.93
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$59.99
|
| 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
|
|
|
ELETRIPTAN 20 MG TABLET [34683]
|
Facility
|
OP
|
$96.92
|
|
|
Service Code
|
NDC 0049-2330-45
|
| 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 |
$56.92
|
| Rate for Payer: Blue Shield of California Commercial |
$59.22
|
| Rate for Payer: Blue Shield of California EPN |
$38.67
|
| Rate for Payer: Cash Price |
$53.31
|
| 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: 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: InnovAge PACE Commercial |
$48.46
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$64.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$36.93
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$59.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$19.38
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$67.84
|
| Rate for Payer: Molina Healthcare of CA 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
|
|
|
ELTROMBOPAG OLAMINE 25 MG TABLET [94579]
|
Facility
|
IP
|
$313.06
|
|
|
Service Code
|
NDC 0078-0685-15
|
| 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 |
$242.00
|
| Rate for Payer: Blue Shield of California EPN |
$157.78
|
| Rate for Payer: Cash Price |
$172.18
|
| 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: 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 Permanente of CA Commercial/Self Funded |
$208.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$119.28
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$193.78
|
| 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
|
|
|
ELTROMBOPAG OLAMINE 25 MG TABLET [94579]
|
Facility
|
OP
|
$313.06
|
|
|
Service Code
|
NDC 0078-0685-15
|
| 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 |
$183.86
|
| Rate for Payer: Blue Shield of California Commercial |
$191.28
|
| Rate for Payer: Blue Shield of California EPN |
$124.91
|
| Rate for Payer: Cash Price |
$172.18
|
| 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: 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: InnovAge PACE Commercial |
$156.53
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$208.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$119.28
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$193.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$62.61
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$219.14
|
| Rate for Payer: Molina Healthcare of CA 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 50 MG TABLET [94580]
|
Facility
|
OP
|
$566.53
|
|
|
Service Code
|
NDC 0078-0686-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$113.31 |
| Max. Negotiated Rate |
$509.88 |
| Rate for Payer: Adventist Health Commercial |
$113.31
|
| Rate for Payer: Aetna of CA HMO/PPO |
$344.05
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$481.55
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$311.59
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$424.90
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$274.31
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$332.72
|
| Rate for Payer: Blue Shield of California Commercial |
$346.15
|
| Rate for Payer: Blue Shield of California EPN |
$226.05
|
| Rate for Payer: Cash Price |
$311.59
|
| Rate for Payer: Central Health Plan Commercial |
$453.22
|
| Rate for Payer: Cigna of CA HMO |
$396.57
|
| Rate for Payer: Cigna of CA PPO |
$396.57
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$481.55
|
| Rate for Payer: Dignity Health Medi-Cal |
$481.55
|
| Rate for Payer: Dignity Health Medicare Advantage |
$481.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$226.61
|
| Rate for Payer: EPIC Health Plan Senior |
$226.61
|
| Rate for Payer: Galaxy Health WC |
$481.55
|
| Rate for Payer: Global Benefits Group Commercial |
$339.92
|
| Rate for Payer: Health Management Network EPO/PPO |
$509.88
|
| Rate for Payer: InnovAge PACE Commercial |
$283.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$377.88
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$215.85
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$350.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$113.31
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$396.57
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$396.57
|
| Rate for Payer: Multiplan Commercial |
$424.90
|
| Rate for Payer: Networks By Design Commercial |
$368.24
|
| Rate for Payer: Prime Health Services Commercial |
$481.55
|
| Rate for Payer: Riverside University Health System MISP |
$226.61
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$339.92
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$339.92
|
| Rate for Payer: United Healthcare All Other Commercial |
$283.26
|
| Rate for Payer: United Healthcare All Other HMO |
$283.26
|
| Rate for Payer: United Healthcare HMO Rider |
$283.26
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$283.26
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$481.55
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$481.55
|
| Rate for Payer: Vantage Medical Group Senior |
$481.55
|
|
|
ELTROMBOPAG OLAMINE 50 MG TABLET [94580]
|
Facility
|
IP
|
$566.53
|
|
|
Service Code
|
NDC 0078-0686-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$113.31 |
| Max. Negotiated Rate |
$509.88 |
| Rate for Payer: Adventist Health Commercial |
$113.31
|
| Rate for Payer: Blue Shield of California Commercial |
$437.93
|
| Rate for Payer: Blue Shield of California EPN |
$285.53
|
| Rate for Payer: Cash Price |
$311.59
|
| Rate for Payer: Central Health Plan Commercial |
$453.22
|
| Rate for Payer: Cigna of CA HMO |
$396.57
|
| Rate for Payer: Cigna of CA PPO |
$396.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$226.61
|
| Rate for Payer: EPIC Health Plan Senior |
$226.61
|
| Rate for Payer: Galaxy Health WC |
$481.55
|
| Rate for Payer: Global Benefits Group Commercial |
$339.92
|
| Rate for Payer: Health Management Network EPO/PPO |
$509.88
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$377.88
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$215.85
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$350.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$113.31
|
| Rate for Payer: Multiplan Commercial |
$424.90
|
| Rate for Payer: Networks By Design Commercial |
$368.24
|
| Rate for Payer: Prime Health Services Commercial |
$481.55
|
|
|
EMOLLIENT COMBINATION NO.10 TOPICAL EMULSION [42944]
|
Facility
|
IP
|
$1.33
|
|
|
Service Code
|
NDC 0187-5110-45
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$1.20 |
| Rate for Payer: Adventist Health Commercial |
$0.27
|
| Rate for Payer: Blue Shield of California Commercial |
$1.03
|
| Rate for Payer: Blue Shield of California EPN |
$0.67
|
| Rate for Payer: Cash Price |
$0.73
|
| Rate for Payer: Central Health Plan Commercial |
$1.06
|
| Rate for Payer: Cigna of CA HMO |
$0.93
|
| Rate for Payer: Cigna of CA PPO |
$0.93
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.53
|
| Rate for Payer: EPIC Health Plan Senior |
$0.53
|
| Rate for Payer: Galaxy Health WC |
$1.13
|
| Rate for Payer: Global Benefits Group Commercial |
$0.80
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.51
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.27
|
| Rate for Payer: Multiplan Commercial |
$1.00
|
| Rate for Payer: Networks By Design Commercial |
$0.86
|
| Rate for Payer: Prime Health Services Commercial |
$1.13
|
|
|
EMOLLIENT COMBINATION NO.10 TOPICAL EMULSION [42944]
|
Facility
|
OP
|
$0.58
|
|
|
Service Code
|
NDC 5898096012
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.52 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.35
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.49
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.32
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.44
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.28
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.34
|
| Rate for Payer: Blue Shield of California Commercial |
$0.35
|
| Rate for Payer: Blue Shield of California EPN |
$0.23
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Central Health Plan Commercial |
$0.46
|
| Rate for Payer: Cigna of CA HMO |
$0.41
|
| Rate for Payer: Cigna of CA PPO |
$0.41
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.49
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.49
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.23
|
| Rate for Payer: EPIC Health Plan Senior |
$0.23
|
| Rate for Payer: Galaxy Health WC |
$0.49
|
| Rate for Payer: Global Benefits Group Commercial |
$0.35
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.52
|
| Rate for Payer: InnovAge PACE Commercial |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.41
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.41
|
| Rate for Payer: Multiplan Commercial |
$0.44
|
| Rate for Payer: Networks By Design Commercial |
$0.38
|
| Rate for Payer: Prime Health Services Commercial |
$0.49
|
| Rate for Payer: Riverside University Health System MISP |
$0.23
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.35
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.35
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.29
|
| Rate for Payer: United Healthcare All Other HMO |
$0.29
|
| Rate for Payer: United Healthcare HMO Rider |
$0.29
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.29
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.49
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.49
|
| Rate for Payer: Vantage Medical Group Senior |
$0.49
|
|
|
EMOLLIENT COMBINATION NO.10 TOPICAL EMULSION [42944]
|
Facility
|
IP
|
$0.58
|
|
|
Service Code
|
NDC 5898096012
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.52 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Blue Shield of California Commercial |
$0.45
|
| Rate for Payer: Blue Shield of California EPN |
$0.29
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Central Health Plan Commercial |
$0.46
|
| Rate for Payer: Cigna of CA HMO |
$0.41
|
| Rate for Payer: Cigna of CA PPO |
$0.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.23
|
| Rate for Payer: EPIC Health Plan Senior |
$0.23
|
| Rate for Payer: Galaxy Health WC |
$0.49
|
| Rate for Payer: Global Benefits Group Commercial |
$0.35
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.52
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.44
|
| Rate for Payer: Networks By Design Commercial |
$0.38
|
| Rate for Payer: Prime Health Services Commercial |
$0.49
|
|
|
EMOLLIENT COMBINATION NO.10 TOPICAL EMULSION [42944]
|
Facility
|
OP
|
$1.33
|
|
|
Service Code
|
NDC 0187-5110-45
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$1.20 |
| Rate for Payer: Adventist Health Commercial |
$0.27
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.81
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.13
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.73
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.00
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.64
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.78
|
| Rate for Payer: Blue Shield of California Commercial |
$0.81
|
| Rate for Payer: Blue Shield of California EPN |
$0.53
|
| Rate for Payer: Cash Price |
$0.73
|
| Rate for Payer: Central Health Plan Commercial |
$1.06
|
| Rate for Payer: Cigna of CA HMO |
$0.93
|
| Rate for Payer: Cigna of CA PPO |
$0.93
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.13
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.13
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.53
|
| Rate for Payer: EPIC Health Plan Senior |
$0.53
|
| Rate for Payer: Galaxy Health WC |
$1.13
|
| Rate for Payer: Global Benefits Group Commercial |
$0.80
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.20
|
| Rate for Payer: InnovAge PACE Commercial |
$0.67
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.51
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.27
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.93
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.93
|
| Rate for Payer: Multiplan Commercial |
$1.00
|
| Rate for Payer: Networks By Design Commercial |
$0.86
|
| Rate for Payer: Prime Health Services Commercial |
$1.13
|
| Rate for Payer: Riverside University Health System MISP |
$0.53
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.80
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.67
|
| Rate for Payer: United Healthcare All Other HMO |
$0.67
|
| Rate for Payer: United Healthcare HMO Rider |
$0.67
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.67
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.13
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.13
|
| Rate for Payer: Vantage Medical Group Senior |
$1.13
|
|
|
EMOLLIENT COMBINATION NO.69 TOPICAL CREAM [196535]
|
Facility
|
OP
|
$0.03
|
|
|
Service Code
|
NDC 7214063378
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.02
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.01
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Central Health Plan Commercial |
$0.02
|
| Rate for Payer: Cigna of CA HMO |
$0.02
|
| Rate for Payer: Cigna of CA PPO |
$0.02
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.03
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: EPIC Health Plan Senior |
$0.01
|
| Rate for Payer: Galaxy Health WC |
$0.03
|
| Rate for Payer: Global Benefits Group Commercial |
$0.02
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.03
|
| Rate for Payer: InnovAge PACE Commercial |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: Networks By Design Commercial |
$0.02
|
| Rate for Payer: Prime Health Services Commercial |
$0.03
|
| Rate for Payer: Riverside University Health System MISP |
$0.01
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.02
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.02
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.02
|
| Rate for Payer: United Healthcare All Other HMO |
$0.02
|
| Rate for Payer: United Healthcare HMO Rider |
$0.02
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Vantage Medical Group Senior |
$0.03
|
|
|
EMOLLIENT COMBINATION NO.69 TOPICAL CREAM [196535]
|
Facility
|
IP
|
$0.03
|
|
|
Service Code
|
NDC 7214063378
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Central Health Plan Commercial |
$0.02
|
| Rate for Payer: Cigna of CA HMO |
$0.02
|
| Rate for Payer: Cigna of CA PPO |
$0.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: EPIC Health Plan Senior |
$0.01
|
| Rate for Payer: Galaxy Health WC |
$0.03
|
| Rate for Payer: Global Benefits Group Commercial |
$0.02
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: Networks By Design Commercial |
$0.02
|
| Rate for Payer: Prime Health Services Commercial |
$0.03
|
|
