|
Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with lithotripsy including insertion of indwelling ureteral stent (eg, Gibbons or double-J type)
|
Facility
OP
|
$25,512.00
|
|
|
Service Code
|
CPT 52356
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4,183.44 |
| Max. Negotiated Rate |
$25,512.00 |
| Rate for Payer: Adventist Health Medi-Cal |
$6,465.01
|
| Rate for Payer: Aetna of CA HMO/PPO |
$10,567.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$9,697.52
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$7,111.51
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$6,465.01
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$4,736.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,779.00
|
| Rate for Payer: Blue Shield of California Commercial |
$5,824.53
|
| Rate for Payer: Blue Shield of California EPN |
$4,183.44
|
| Rate for Payer: Caremore Medicare Advantage |
$6,465.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9,697.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$8,727.76
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$6,465.01
|
| Rate for Payer: EPIC Health Plan Transplant |
$6,465.01
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$10,602.62
|
| Rate for Payer: IEHP medi-cal |
$10,667.27
|
| Rate for Payer: IEHP Medicare Advantage |
$6,465.01
|
| Rate for Payer: Innovage PACE Commercial |
$9,697.52
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$6,465.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$8,663.11
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$8,663.11
|
| Rate for Payer: Prime Health Services Medicare |
$6,852.91
|
| Rate for Payer: Riverside University Health MISP |
$7,111.51
|
| Rate for Payer: United Healthcare All Other Commercial |
$14,836.00
|
| Rate for Payer: United Healthcare All Other HMO |
$25,512.00
|
| Rate for Payer: United Healthcare HMO Rider |
$16,069.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$14,692.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$9,697.52
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7,111.51
|
| Rate for Payer: Vantage Medical Group Senior |
$6,465.01
|
|
|
Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with lithotripsy (ureteral catheterization is included)
|
Facility
OP
|
$25,512.00
|
|
|
Service Code
|
CPT 52353
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4,183.44 |
| Max. Negotiated Rate |
$25,512.00 |
| Rate for Payer: Adventist Health Medi-Cal |
$6,465.01
|
| Rate for Payer: Aetna of CA HMO/PPO |
$10,567.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$9,697.52
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$7,111.51
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$6,465.01
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$4,736.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,779.00
|
| Rate for Payer: Blue Shield of California Commercial |
$5,824.53
|
| Rate for Payer: Blue Shield of California EPN |
$4,183.44
|
| Rate for Payer: Caremore Medicare Advantage |
$6,465.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9,697.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$8,727.76
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$6,465.01
|
| Rate for Payer: EPIC Health Plan Transplant |
$6,465.01
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$10,602.62
|
| Rate for Payer: IEHP medi-cal |
$10,667.27
|
| Rate for Payer: IEHP Medicare Advantage |
$6,465.01
|
| Rate for Payer: Innovage PACE Commercial |
$9,697.52
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$6,465.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$8,663.11
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$8,663.11
|
| Rate for Payer: Prime Health Services Medicare |
$6,852.91
|
| Rate for Payer: Riverside University Health MISP |
$7,111.51
|
| Rate for Payer: United Healthcare All Other Commercial |
$14,836.00
|
| Rate for Payer: United Healthcare All Other HMO |
$25,512.00
|
| Rate for Payer: United Healthcare HMO Rider |
$16,069.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$14,692.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$9,697.52
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7,111.51
|
| Rate for Payer: Vantage Medical Group Senior |
$6,465.01
|
|
|
Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with removal or manipulation of calculus (ureteral catheterization is included)
|
Facility
OP
|
$15,354.00
|
|
|
Service Code
|
CPT 52352
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4,183.44 |
| Max. Negotiated Rate |
$15,354.00 |
| Rate for Payer: Adventist Health Medi-Cal |
$4,355.72
|
| Rate for Payer: Aetna of CA HMO/PPO |
$10,567.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$6,533.58
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4,791.29
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4,355.72
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$4,736.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,779.00
|
| Rate for Payer: Blue Shield of California Commercial |
$5,824.53
|
| Rate for Payer: Blue Shield of California EPN |
$4,183.44
|
| Rate for Payer: Caremore Medicare Advantage |
$4,355.72
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,533.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$5,880.22
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$4,355.72
|
| Rate for Payer: EPIC Health Plan Transplant |
$4,355.72
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$7,143.38
|
| Rate for Payer: IEHP medi-cal |
$7,186.94
|
| Rate for Payer: IEHP Medicare Advantage |
$4,355.72
|
| Rate for Payer: Innovage PACE Commercial |
$6,533.58
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4,355.72
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5,836.66
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5,836.66
|
| Rate for Payer: Prime Health Services Medicare |
$4,617.06
|
| Rate for Payer: Riverside University Health MISP |
$4,791.29
|
| Rate for Payer: United Healthcare All Other Commercial |
$11,375.00
|
| Rate for Payer: United Healthcare All Other HMO |
$15,354.00
|
| Rate for Payer: United Healthcare HMO Rider |
$9,681.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$8,852.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,533.58
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,791.29
|
| Rate for Payer: Vantage Medical Group Senior |
$4,355.72
|
|
|
CYTARABINE (PF) 100 MG/5 ML (20 MG/ML) INJECTION SOLUTION [120408]
|
Facility
OP
|
$1.52
|
|
|
Service Code
|
CPT J9100
|
| Hospital Charge Code |
NDG120408
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$14.04 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.91
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.29
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.84
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.84
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$12.83
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$14.04
|
| Rate for Payer: BCBS Transplant Transplant |
$0.91
|
| Rate for Payer: Blue Shield of California Commercial |
$1.27
|
| Rate for Payer: Blue Shield of California EPN |
$1.15
|
| Rate for Payer: Cash Price |
$0.68
|
| Rate for Payer: Cash Price |
$0.68
|
| Rate for Payer: Central Health Plan Commercial |
$1.22
|
| Rate for Payer: Cigna of CA HMO |
$1.06
|
| Rate for Payer: Cigna of CA PPO |
$1.06
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.61
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.61
|
| Rate for Payer: Galaxy Health WC |
$1.29
|
| Rate for Payer: Global Benefits Group Commercial |
$0.91
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.37
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1.14
|
| Rate for Payer: IEHP medi-cal |
$0.76
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Multiplan Commercial |
$1.14
|
| Rate for Payer: Networks By Design Commercial |
$0.76
|
| Rate for Payer: Prime Health Services Commercial |
$1.29
|
| Rate for Payer: Riverside University Health MISP |
$0.61
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.91
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.91
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.76
|
| Rate for Payer: United Healthcare All Other HMO |
$0.76
|
| Rate for Payer: United Healthcare HMO Rider |
$0.76
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.76
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.29
|
| Rate for Payer: Vantage Medical Group Senior |
$1.29
|
|
|
CYTARABINE (PF) 100 MG/5 ML (20 MG/ML) INJECTION SOLUTION [120408]
|
Facility
IP
|
$1.52
|
|
|
Service Code
|
CPT J9100
|
| Hospital Charge Code |
NDG120408
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$1.37 |
| Rate for Payer: Blue Shield of California Commercial |
$1.14
|
| Rate for Payer: Blue Shield of California EPN |
$0.81
|
| Rate for Payer: Cash Price |
$0.68
|
| Rate for Payer: Central Health Plan Commercial |
$1.22
|
| Rate for Payer: Cigna of CA HMO |
$1.06
|
| Rate for Payer: Cigna of CA PPO |
$1.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.61
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.61
|
| Rate for Payer: Galaxy Health WC |
$1.29
|
| Rate for Payer: Global Benefits Group Commercial |
$0.91
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Multiplan Commercial |
$1.14
|
| Rate for Payer: Networks By Design Commercial |
$0.76
|
| Rate for Payer: Prime Health Services Commercial |
$1.29
|
|
|
CYTARABINE (PF) 2 GRAM/20 ML (100 MG/ML) INJECTION SOLUTION [20156]
|
Facility
OP
|
$1.22
|
|
|
Service Code
|
CPT J9100
|
| Hospital Charge Code |
NDG20156
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$14.04 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.91
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.91
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.04
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.06
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.69
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.67
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.69
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.67
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$12.83
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$12.83
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$14.04
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$14.04
|
| Rate for Payer: BCBS Transplant Transplant |
$0.73
|
| Rate for Payer: BCBS Transplant Transplant |
$0.75
|
| Rate for Payer: Blue Shield of California Commercial |
$1.27
|
| Rate for Payer: Blue Shield of California Commercial |
$1.27
|
| Rate for Payer: Blue Shield of California EPN |
$1.15
|
| Rate for Payer: Blue Shield of California EPN |
$1.15
|
| Rate for Payer: Cash Price |
$0.56
|
| Rate for Payer: Cash Price |
$0.56
|
| Rate for Payer: Cash Price |
$0.55
|
| Rate for Payer: Cash Price |
$0.55
|
| Rate for Payer: Central Health Plan Commercial |
$1.00
|
| Rate for Payer: Central Health Plan Commercial |
$0.98
|
| Rate for Payer: Cigna of CA HMO |
$0.85
|
| Rate for Payer: Cigna of CA HMO |
$0.88
|
| Rate for Payer: Cigna of CA PPO |
$0.88
|
| Rate for Payer: Cigna of CA PPO |
$0.85
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.49
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.49
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.50
|
| Rate for Payer: Galaxy Health WC |
$1.06
|
| Rate for Payer: Galaxy Health WC |
$1.04
|
| Rate for Payer: Global Benefits Group Commercial |
$0.73
|
| Rate for Payer: Global Benefits Group Commercial |
$0.75
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.10
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.12
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.92
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.94
|
| Rate for Payer: IEHP medi-cal |
$0.76
|
| Rate for Payer: IEHP medi-cal |
$0.76
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.81
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
| Rate for Payer: Multiplan Commercial |
$0.92
|
| Rate for Payer: Multiplan Commercial |
$0.94
|
| Rate for Payer: Networks By Design Commercial |
$0.61
|
| Rate for Payer: Networks By Design Commercial |
$0.63
|
| Rate for Payer: Prime Health Services Commercial |
$1.04
|
| Rate for Payer: Prime Health Services Commercial |
$1.06
|
| Rate for Payer: Riverside University Health MISP |
$0.49
|
| Rate for Payer: Riverside University Health MISP |
$0.50
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.75
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.73
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.73
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.75
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.61
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.63
|
| Rate for Payer: United Healthcare All Other HMO |
$0.61
|
| Rate for Payer: United Healthcare All Other HMO |
$0.63
|
| Rate for Payer: United Healthcare HMO Rider |
$0.61
|
| Rate for Payer: United Healthcare HMO Rider |
$0.63
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.63
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.61
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.06
|
| Rate for Payer: Vantage Medical Group Senior |
$1.06
|
| Rate for Payer: Vantage Medical Group Senior |
$1.04
|
|
|
CYTARABINE (PF) 2 GRAM/20 ML (100 MG/ML) INJECTION SOLUTION [20156]
|
Facility
IP
|
$1.22
|
|
|
Service Code
|
CPT J9100
|
| Hospital Charge Code |
NDG20156
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$1.10 |
| Rate for Payer: Blue Shield of California Commercial |
$0.92
|
| Rate for Payer: Blue Shield of California Commercial |
$0.94
|
| Rate for Payer: Blue Shield of California EPN |
$0.67
|
| Rate for Payer: Blue Shield of California EPN |
$0.65
|
| Rate for Payer: Cash Price |
$0.55
|
| Rate for Payer: Cash Price |
$0.56
|
| Rate for Payer: Central Health Plan Commercial |
$1.00
|
| Rate for Payer: Central Health Plan Commercial |
$0.98
|
| Rate for Payer: Cigna of CA HMO |
$0.85
|
| Rate for Payer: Cigna of CA HMO |
$0.88
|
| Rate for Payer: Cigna of CA PPO |
$0.88
|
| Rate for Payer: Cigna of CA PPO |
$0.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.50
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.50
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.49
|
| Rate for Payer: Galaxy Health WC |
$1.04
|
| Rate for Payer: Galaxy Health WC |
$1.06
|
| Rate for Payer: Global Benefits Group Commercial |
$0.75
|
| Rate for Payer: Global Benefits Group Commercial |
$0.73
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.10
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.81
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
| Rate for Payer: Multiplan Commercial |
$0.94
|
| Rate for Payer: Multiplan Commercial |
$0.92
|
| Rate for Payer: Networks By Design Commercial |
$0.61
|
| Rate for Payer: Networks By Design Commercial |
$0.63
|
| Rate for Payer: Prime Health Services Commercial |
$1.04
|
| Rate for Payer: Prime Health Services Commercial |
$1.06
|
|
|
CYTOMEGALOVIRUS IMMUNE GLOBULIN 50 MG/ML INTRAVENOUS SOLUTION [14634]
|
Facility
IP
|
$42.16
|
|
|
Service Code
|
CPT J0850
|
| Hospital Charge Code |
1758636
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.43 |
| Max. Negotiated Rate |
$37.94 |
| Rate for Payer: Blue Shield of California Commercial |
$31.62
|
| Rate for Payer: Blue Shield of California Commercial |
$26.66
|
| Rate for Payer: Blue Shield of California EPN |
$22.51
|
| Rate for Payer: Blue Shield of California EPN |
$18.98
|
| Rate for Payer: Cash Price |
$18.97
|
| Rate for Payer: Cash Price |
$16.00
|
| Rate for Payer: Central Health Plan Commercial |
$33.73
|
| Rate for Payer: Central Health Plan Commercial |
$28.44
|
| Rate for Payer: Cigna of CA HMO |
$24.88
|
| Rate for Payer: Cigna of CA HMO |
$29.51
|
| Rate for Payer: Cigna of CA PPO |
$29.51
|
| Rate for Payer: Cigna of CA PPO |
$24.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$16.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.22
|
| Rate for Payer: EPIC Health Plan Transplant |
$14.22
|
| Rate for Payer: EPIC Health Plan Transplant |
$16.86
|
| Rate for Payer: Galaxy Health WC |
$35.84
|
| Rate for Payer: Galaxy Health WC |
$30.22
|
| Rate for Payer: Global Benefits Group Commercial |
$21.33
|
| Rate for Payer: Global Benefits Group Commercial |
$25.30
|
| Rate for Payer: Health Management Network EPO/PPO |
$37.94
|
| Rate for Payer: Health Management Network EPO/PPO |
$32.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$28.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$23.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.43
|
| Rate for Payer: Multiplan Commercial |
$26.66
|
| Rate for Payer: Multiplan Commercial |
$31.62
|
| Rate for Payer: Networks By Design Commercial |
$21.08
|
| Rate for Payer: Networks By Design Commercial |
$17.78
|
| Rate for Payer: Prime Health Services Commercial |
$30.22
|
| Rate for Payer: Prime Health Services Commercial |
$35.84
|
|
|
CYTOMEGALOVIRUS IMMUNE GLOBULIN 50 MG/ML INTRAVENOUS SOLUTION [14634]
|
Facility
OP
|
$35.55
|
|
|
Service Code
|
CPT J0850
|
| Hospital Charge Code |
1758636
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.11 |
| Max. Negotiated Rate |
$11,203.48 |
| Rate for Payer: Adventist Health Medi-Cal |
$1,807.87
|
| Rate for Payer: Adventist Health Medi-Cal |
$1,807.87
|
| Rate for Payer: Aetna of CA HMO/PPO |
$11,203.48
|
| Rate for Payer: Aetna of CA HMO/PPO |
$11,203.48
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2,259.84
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2,259.84
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1,988.66
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1,988.66
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1,988.66
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1,988.66
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1,335.09
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1,335.09
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,461.78
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,461.78
|
| Rate for Payer: BCBS Transplant Transplant |
$21.33
|
| Rate for Payer: BCBS Transplant Transplant |
$25.30
|
| Rate for Payer: Blue Shield of California Commercial |
$1,864.13
|
| Rate for Payer: Blue Shield of California Commercial |
$1,864.13
|
| Rate for Payer: Blue Shield of California EPN |
$1,694.66
|
| Rate for Payer: Blue Shield of California EPN |
$1,694.66
|
| Rate for Payer: Caremore Medicare Advantage |
$1,807.87
|
| Rate for Payer: Caremore Medicare Advantage |
$1,807.87
|
| Rate for Payer: Cash Price |
$16.00
|
| Rate for Payer: Cash Price |
$18.97
|
| Rate for Payer: Cash Price |
$18.97
|
| Rate for Payer: Cash Price |
$16.00
|
| Rate for Payer: Central Health Plan Commercial |
$33.73
|
| Rate for Payer: Central Health Plan Commercial |
$28.44
|
| Rate for Payer: Cigna of CA HMO |
$24.88
|
| Rate for Payer: Cigna of CA HMO |
$29.51
|
| Rate for Payer: Cigna of CA PPO |
$29.51
|
| Rate for Payer: Cigna of CA PPO |
$24.88
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2,711.81
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2,711.81
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,440.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,440.63
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$1,807.87
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$1,807.87
|
| Rate for Payer: EPIC Health Plan Transplant |
$1,807.87
|
| Rate for Payer: EPIC Health Plan Transplant |
$1,807.87
|
| Rate for Payer: Galaxy Health WC |
$35.84
|
| Rate for Payer: Galaxy Health WC |
$30.22
|
| Rate for Payer: Global Benefits Group Commercial |
$21.33
|
| Rate for Payer: Global Benefits Group Commercial |
$25.30
|
| Rate for Payer: Health Management Network EPO/PPO |
$37.94
|
| Rate for Payer: Health Management Network EPO/PPO |
$32.00
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$31.62
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$26.66
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$2,964.91
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$2,964.91
|
| Rate for Payer: IEHP medi-cal |
$2,982.99
|
| Rate for Payer: IEHP medi-cal |
$2,982.99
|
| Rate for Payer: IEHP Medicare Advantage |
$1,807.87
|
| Rate for Payer: IEHP Medicare Advantage |
$1,807.87
|
| Rate for Payer: Innovage PACE Commercial |
$2,711.81
|
| Rate for Payer: Innovage PACE Commercial |
$2,711.81
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$23.71
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$28.12
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,807.87
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,807.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.43
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,422.55
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,422.55
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,422.55
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,422.55
|
| Rate for Payer: Multiplan Commercial |
$31.62
|
| Rate for Payer: Multiplan Commercial |
$26.66
|
| Rate for Payer: Networks By Design Commercial |
$17.78
|
| Rate for Payer: Networks By Design Commercial |
$21.08
|
| Rate for Payer: Prime Health Services Commercial |
$35.84
|
| Rate for Payer: Prime Health Services Commercial |
$30.22
|
| Rate for Payer: Prime Health Services Medicare |
$1,916.34
|
| Rate for Payer: Prime Health Services Medicare |
$1,916.34
|
| Rate for Payer: Riverside University Health MISP |
$1,988.66
|
| Rate for Payer: Riverside University Health MISP |
$1,988.66
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$21.33
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$25.30
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$21.33
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$25.30
|
| Rate for Payer: United Healthcare All Other Commercial |
$21.08
|
| Rate for Payer: United Healthcare All Other Commercial |
$17.78
|
| Rate for Payer: United Healthcare All Other HMO |
$21.08
|
| Rate for Payer: United Healthcare All Other HMO |
$17.78
|
| Rate for Payer: United Healthcare HMO Rider |
$17.78
|
| Rate for Payer: United Healthcare HMO Rider |
$21.08
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$21.08
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$17.78
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2,711.81
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2,711.81
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,988.66
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,988.66
|
| Rate for Payer: Vantage Medical Group Senior |
$1,807.87
|
| Rate for Payer: Vantage Medical Group Senior |
$1,807.87
|
|
|
DABIGATRAN ETEXILATE 110 MG CAPSULE [212609]
|
Facility
OP
|
$3.97
|
|
|
Service Code
|
NDC 0597-0108-54
|
| Hospital Charge Code |
ERX212609
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.79 |
| Max. Negotiated Rate |
$3.57 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2.41
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3.37
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.18
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.18
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1.92
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.35
|
| Rate for Payer: BCBS Transplant Transplant |
$2.38
|
| Rate for Payer: Blue Shield of California Commercial |
$2.50
|
| Rate for Payer: Blue Shield of California EPN |
$1.94
|
| Rate for Payer: Cash Price |
$1.79
|
| Rate for Payer: Central Health Plan Commercial |
$3.18
|
| Rate for Payer: Cigna of CA HMO |
$2.78
|
| Rate for Payer: Cigna of CA PPO |
$2.78
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.59
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.59
|
| Rate for Payer: Galaxy Health WC |
$3.37
|
| Rate for Payer: Global Benefits Group Commercial |
$2.38
|
| Rate for Payer: Health Management Network EPO/PPO |
$3.57
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$2.98
|
| Rate for Payer: IEHP medi-cal |
$1.39
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.79
|
| Rate for Payer: Multiplan Commercial |
$2.98
|
| Rate for Payer: Networks By Design Commercial |
$2.58
|
| Rate for Payer: Prime Health Services Commercial |
$3.37
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$2.38
|
| Rate for Payer: Riverside University Health MISP |
$1.59
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.38
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.38
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.98
|
| Rate for Payer: United Healthcare All Other HMO |
$1.98
|
| Rate for Payer: United Healthcare HMO Rider |
$1.98
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.98
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.37
|
| Rate for Payer: Vantage Medical Group Senior |
$3.37
|
|
|
DABIGATRAN ETEXILATE 110 MG CAPSULE [212609]
|
Facility
IP
|
$3.97
|
|
|
Service Code
|
NDC 0597-0108-54
|
| Hospital Charge Code |
ERX212609
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.79 |
| Max. Negotiated Rate |
$3.57 |
| Rate for Payer: Blue Shield of California Commercial |
$2.98
|
| Rate for Payer: Blue Shield of California EPN |
$2.12
|
| Rate for Payer: Cash Price |
$1.79
|
| Rate for Payer: Central Health Plan Commercial |
$3.18
|
| Rate for Payer: Cigna of CA HMO |
$2.78
|
| Rate for Payer: Cigna of CA PPO |
$2.78
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.59
|
| Rate for Payer: Galaxy Health WC |
$3.37
|
| Rate for Payer: Global Benefits Group Commercial |
$2.38
|
| Rate for Payer: Health Management Network EPO/PPO |
$3.57
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.79
|
| Rate for Payer: Multiplan Commercial |
$2.98
|
| Rate for Payer: Networks By Design Commercial |
$2.58
|
| Rate for Payer: Prime Health Services Commercial |
$3.37
|
|
|
DABIGATRAN ETEXILATE 150 MG CAPSULE [106491]
|
Facility
IP
|
$3.97
|
|
|
Service Code
|
NDC 0597-0360-82
|
| Hospital Charge Code |
1712463
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.79 |
| Max. Negotiated Rate |
$3.57 |
| Rate for Payer: Blue Shield of California Commercial |
$2.98
|
| Rate for Payer: Blue Shield of California EPN |
$2.12
|
| Rate for Payer: Cash Price |
$1.79
|
| Rate for Payer: Central Health Plan Commercial |
$3.18
|
| Rate for Payer: Cigna of CA HMO |
$2.78
|
| Rate for Payer: Cigna of CA PPO |
$2.78
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.59
|
| Rate for Payer: Galaxy Health WC |
$3.37
|
| Rate for Payer: Global Benefits Group Commercial |
$2.38
|
| Rate for Payer: Health Management Network EPO/PPO |
$3.57
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.79
|
| Rate for Payer: Multiplan Commercial |
$2.98
|
| Rate for Payer: Networks By Design Commercial |
$2.58
|
| Rate for Payer: Prime Health Services Commercial |
$3.37
|
|
|
DABIGATRAN ETEXILATE 150 MG CAPSULE [106491]
|
Facility
OP
|
$3.97
|
|
|
Service Code
|
NDC 0597-0360-55
|
| Hospital Charge Code |
1712463
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.79 |
| Max. Negotiated Rate |
$3.57 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2.41
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3.37
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.18
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.18
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1.92
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.35
|
| Rate for Payer: BCBS Transplant Transplant |
$2.38
|
| Rate for Payer: Blue Shield of California Commercial |
$2.50
|
| Rate for Payer: Blue Shield of California EPN |
$1.94
|
| Rate for Payer: Cash Price |
$1.79
|
| Rate for Payer: Central Health Plan Commercial |
$3.18
|
| Rate for Payer: Cigna of CA HMO |
$2.78
|
| Rate for Payer: Cigna of CA PPO |
$2.78
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.59
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.59
|
| Rate for Payer: Galaxy Health WC |
$3.37
|
| Rate for Payer: Global Benefits Group Commercial |
$2.38
|
| Rate for Payer: Health Management Network EPO/PPO |
$3.57
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$2.98
|
| Rate for Payer: IEHP medi-cal |
$1.39
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.79
|
| Rate for Payer: Multiplan Commercial |
$2.98
|
| Rate for Payer: Networks By Design Commercial |
$2.58
|
| Rate for Payer: Prime Health Services Commercial |
$3.37
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$2.38
|
| Rate for Payer: Riverside University Health MISP |
$1.59
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.38
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.38
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.98
|
| Rate for Payer: United Healthcare All Other HMO |
$1.98
|
| Rate for Payer: United Healthcare HMO Rider |
$1.98
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.98
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.37
|
| Rate for Payer: Vantage Medical Group Senior |
$3.37
|
|
|
DABIGATRAN ETEXILATE 150 MG CAPSULE [106491]
|
Facility
IP
|
$3.97
|
|
|
Service Code
|
NDC 0597-0360-55
|
| Hospital Charge Code |
1712463
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.79 |
| Max. Negotiated Rate |
$3.57 |
| Rate for Payer: Blue Shield of California Commercial |
$2.98
|
| Rate for Payer: Blue Shield of California EPN |
$2.12
|
| Rate for Payer: Cash Price |
$1.79
|
| Rate for Payer: Central Health Plan Commercial |
$3.18
|
| Rate for Payer: Cigna of CA HMO |
$2.78
|
| Rate for Payer: Cigna of CA PPO |
$2.78
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.59
|
| Rate for Payer: Galaxy Health WC |
$3.37
|
| Rate for Payer: Global Benefits Group Commercial |
$2.38
|
| Rate for Payer: Health Management Network EPO/PPO |
$3.57
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.79
|
| Rate for Payer: Multiplan Commercial |
$2.98
|
| Rate for Payer: Networks By Design Commercial |
$2.58
|
| Rate for Payer: Prime Health Services Commercial |
$3.37
|
|
|
DABIGATRAN ETEXILATE 150 MG CAPSULE [106491]
|
Facility
OP
|
$3.97
|
|
|
Service Code
|
NDC 0597-0360-82
|
| Hospital Charge Code |
1712463
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.79 |
| Max. Negotiated Rate |
$3.57 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2.41
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3.37
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.18
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.18
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1.92
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.35
|
| Rate for Payer: BCBS Transplant Transplant |
$2.38
|
| Rate for Payer: Blue Shield of California Commercial |
$2.50
|
| Rate for Payer: Blue Shield of California EPN |
$1.94
|
| Rate for Payer: Cash Price |
$1.79
|
| Rate for Payer: Central Health Plan Commercial |
$3.18
|
| Rate for Payer: Cigna of CA HMO |
$2.78
|
| Rate for Payer: Cigna of CA PPO |
$2.78
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.59
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.59
|
| Rate for Payer: Galaxy Health WC |
$3.37
|
| Rate for Payer: Global Benefits Group Commercial |
$2.38
|
| Rate for Payer: Health Management Network EPO/PPO |
$3.57
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$2.98
|
| Rate for Payer: IEHP medi-cal |
$1.39
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.79
|
| Rate for Payer: Multiplan Commercial |
$2.98
|
| Rate for Payer: Networks By Design Commercial |
$2.58
|
| Rate for Payer: Prime Health Services Commercial |
$3.37
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$2.38
|
| Rate for Payer: Riverside University Health MISP |
$1.59
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.38
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.38
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.98
|
| Rate for Payer: United Healthcare All Other HMO |
$1.98
|
| Rate for Payer: United Healthcare HMO Rider |
$1.98
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.98
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.37
|
| Rate for Payer: Vantage Medical Group Senior |
$3.37
|
|
|
DABIGATRAN ETEXILATE 75 MG CAPSULE [106490]
|
Facility
IP
|
$3.97
|
|
|
Service Code
|
NDC 0597-0355-56
|
| Hospital Charge Code |
1712462
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.79 |
| Max. Negotiated Rate |
$3.57 |
| Rate for Payer: Blue Shield of California Commercial |
$2.98
|
| Rate for Payer: Blue Shield of California EPN |
$2.12
|
| Rate for Payer: Cash Price |
$1.79
|
| Rate for Payer: Central Health Plan Commercial |
$3.18
|
| Rate for Payer: Cigna of CA HMO |
$2.78
|
| Rate for Payer: Cigna of CA PPO |
$2.78
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.59
|
| Rate for Payer: Galaxy Health WC |
$3.37
|
| Rate for Payer: Global Benefits Group Commercial |
$2.38
|
| Rate for Payer: Health Management Network EPO/PPO |
$3.57
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.79
|
| Rate for Payer: Multiplan Commercial |
$2.98
|
| Rate for Payer: Networks By Design Commercial |
$2.58
|
| Rate for Payer: Prime Health Services Commercial |
$3.37
|
|
|
DABIGATRAN ETEXILATE 75 MG CAPSULE [106490]
|
Facility
OP
|
$3.97
|
|
|
Service Code
|
NDC 0597-0355-56
|
| Hospital Charge Code |
1712462
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.79 |
| Max. Negotiated Rate |
$3.57 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2.41
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3.37
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.18
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.18
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1.92
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.35
|
| Rate for Payer: BCBS Transplant Transplant |
$2.38
|
| Rate for Payer: Blue Shield of California Commercial |
$2.50
|
| Rate for Payer: Blue Shield of California EPN |
$1.94
|
| Rate for Payer: Cash Price |
$1.79
|
| Rate for Payer: Central Health Plan Commercial |
$3.18
|
| Rate for Payer: Cigna of CA HMO |
$2.78
|
| Rate for Payer: Cigna of CA PPO |
$2.78
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.59
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.59
|
| Rate for Payer: Galaxy Health WC |
$3.37
|
| Rate for Payer: Global Benefits Group Commercial |
$2.38
|
| Rate for Payer: Health Management Network EPO/PPO |
$3.57
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$2.98
|
| Rate for Payer: IEHP medi-cal |
$1.39
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.79
|
| Rate for Payer: Multiplan Commercial |
$2.98
|
| Rate for Payer: Networks By Design Commercial |
$2.58
|
| Rate for Payer: Prime Health Services Commercial |
$3.37
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$2.38
|
| Rate for Payer: Riverside University Health MISP |
$1.59
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.38
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.38
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.98
|
| Rate for Payer: United Healthcare All Other HMO |
$1.98
|
| Rate for Payer: United Healthcare HMO Rider |
$1.98
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.98
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.37
|
| Rate for Payer: Vantage Medical Group Senior |
$3.37
|
|
|
DACARBAZINE 100 MG INTRAVENOUS SOLUTION [2090]
|
Facility
IP
|
$13.04
|
|
|
Service Code
|
CPT J9130
|
| Hospital Charge Code |
1720153
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.61 |
| Max. Negotiated Rate |
$11.74 |
| Rate for Payer: Blue Shield of California Commercial |
$9.78
|
| Rate for Payer: Blue Shield of California EPN |
$6.96
|
| Rate for Payer: Cash Price |
$5.87
|
| Rate for Payer: Central Health Plan Commercial |
$10.43
|
| Rate for Payer: Cigna of CA HMO |
$9.13
|
| Rate for Payer: Cigna of CA PPO |
$9.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.22
|
| Rate for Payer: EPIC Health Plan Transplant |
$5.22
|
| Rate for Payer: Galaxy Health WC |
$11.08
|
| Rate for Payer: Global Benefits Group Commercial |
$7.82
|
| Rate for Payer: Health Management Network EPO/PPO |
$11.74
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$8.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.61
|
| Rate for Payer: Multiplan Commercial |
$9.78
|
| Rate for Payer: Networks By Design Commercial |
$6.52
|
| Rate for Payer: Prime Health Services Commercial |
$11.08
|
|
|
DACARBAZINE 100 MG INTRAVENOUS SOLUTION [2090]
|
Facility
OP
|
$13.04
|
|
|
Service Code
|
CPT J9130
|
| Hospital Charge Code |
1720153
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.61 |
| Max. Negotiated Rate |
$27.81 |
| Rate for Payer: Aetna of CA HMO/PPO |
$7.35
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$11.08
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$7.17
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$7.17
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$25.40
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$27.81
|
| Rate for Payer: BCBS Transplant Transplant |
$7.82
|
| Rate for Payer: Blue Shield of California Commercial |
$9.65
|
| Rate for Payer: Blue Shield of California EPN |
$8.77
|
| Rate for Payer: Cash Price |
$5.87
|
| Rate for Payer: Cash Price |
$5.87
|
| Rate for Payer: Central Health Plan Commercial |
$10.43
|
| Rate for Payer: Cigna of CA HMO |
$9.13
|
| Rate for Payer: Cigna of CA PPO |
$9.13
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.22
|
| Rate for Payer: EPIC Health Plan Transplant |
$5.22
|
| Rate for Payer: Galaxy Health WC |
$11.08
|
| Rate for Payer: Global Benefits Group Commercial |
$7.82
|
| Rate for Payer: Health Management Network EPO/PPO |
$11.74
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$9.78
|
| Rate for Payer: IEHP medi-cal |
$3.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$8.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.61
|
| Rate for Payer: Multiplan Commercial |
$9.78
|
| Rate for Payer: Networks By Design Commercial |
$6.52
|
| Rate for Payer: Prime Health Services Commercial |
$11.08
|
| Rate for Payer: Riverside University Health MISP |
$5.22
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$7.82
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$7.82
|
| Rate for Payer: United Healthcare All Other Commercial |
$6.52
|
| Rate for Payer: United Healthcare All Other HMO |
$6.52
|
| Rate for Payer: United Healthcare HMO Rider |
$6.52
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6.52
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$11.08
|
| Rate for Payer: Vantage Medical Group Senior |
$11.08
|
|
|
DACARBAZINE 200 MG INTRAVENOUS SOLUTION [2091]
|
Facility
OP
|
$14.40
|
|
|
Service Code
|
CPT J9130
|
| Hospital Charge Code |
1755114
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.88 |
| Max. Negotiated Rate |
$27.81 |
| Rate for Payer: Aetna of CA HMO/PPO |
$7.35
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$12.24
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$7.92
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$7.92
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$25.40
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$27.81
|
| Rate for Payer: BCBS Transplant Transplant |
$8.64
|
| Rate for Payer: Blue Shield of California Commercial |
$9.65
|
| Rate for Payer: Blue Shield of California EPN |
$8.77
|
| Rate for Payer: Cash Price |
$6.48
|
| Rate for Payer: Cash Price |
$6.48
|
| Rate for Payer: Central Health Plan Commercial |
$11.52
|
| Rate for Payer: Cigna of CA HMO |
$10.08
|
| Rate for Payer: Cigna of CA PPO |
$10.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$12.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.76
|
| Rate for Payer: EPIC Health Plan Transplant |
$5.76
|
| Rate for Payer: Galaxy Health WC |
$12.24
|
| Rate for Payer: Global Benefits Group Commercial |
$8.64
|
| Rate for Payer: Health Management Network EPO/PPO |
$12.96
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$10.80
|
| Rate for Payer: IEHP medi-cal |
$3.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$9.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.88
|
| Rate for Payer: Multiplan Commercial |
$10.80
|
| Rate for Payer: Networks By Design Commercial |
$7.20
|
| Rate for Payer: Prime Health Services Commercial |
$12.24
|
| Rate for Payer: Riverside University Health MISP |
$5.76
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$8.64
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$8.64
|
| Rate for Payer: United Healthcare All Other Commercial |
$7.20
|
| Rate for Payer: United Healthcare All Other HMO |
$7.20
|
| Rate for Payer: United Healthcare HMO Rider |
$7.20
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$7.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$12.24
|
| Rate for Payer: Vantage Medical Group Senior |
$12.24
|
|
|
DACARBAZINE 200 MG INTRAVENOUS SOLUTION [2091]
|
Facility
IP
|
$14.40
|
|
|
Service Code
|
CPT J9130
|
| Hospital Charge Code |
1755114
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.88 |
| Max. Negotiated Rate |
$12.96 |
| Rate for Payer: Blue Shield of California Commercial |
$10.80
|
| Rate for Payer: Blue Shield of California EPN |
$7.69
|
| Rate for Payer: Cash Price |
$6.48
|
| Rate for Payer: Central Health Plan Commercial |
$11.52
|
| Rate for Payer: Cigna of CA HMO |
$10.08
|
| Rate for Payer: Cigna of CA PPO |
$10.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.76
|
| Rate for Payer: EPIC Health Plan Transplant |
$5.76
|
| Rate for Payer: Galaxy Health WC |
$12.24
|
| Rate for Payer: Global Benefits Group Commercial |
$8.64
|
| Rate for Payer: Health Management Network EPO/PPO |
$12.96
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$9.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.88
|
| Rate for Payer: Multiplan Commercial |
$10.80
|
| Rate for Payer: Networks By Design Commercial |
$7.20
|
| Rate for Payer: Prime Health Services Commercial |
$12.24
|
|
|
DACOMITINIB 15 MG TABLET [222938]
|
Facility
IP
|
$622.49
|
|
|
Service Code
|
NDC 0069-0197-30
|
| Hospital Charge Code |
ERX222938
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$124.50 |
| Max. Negotiated Rate |
$560.24 |
| Rate for Payer: Blue Shield of California Commercial |
$466.87
|
| Rate for Payer: Blue Shield of California EPN |
$332.41
|
| Rate for Payer: Cash Price |
$280.12
|
| Rate for Payer: Central Health Plan Commercial |
$497.99
|
| Rate for Payer: Cigna of CA HMO |
$435.74
|
| Rate for Payer: Cigna of CA PPO |
$435.74
|
| Rate for Payer: EPIC Health Plan Commercial |
$249.00
|
| Rate for Payer: Galaxy Health WC |
$529.12
|
| Rate for Payer: Global Benefits Group Commercial |
$373.49
|
| Rate for Payer: Health Management Network EPO/PPO |
$560.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$415.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$124.50
|
| Rate for Payer: Multiplan Commercial |
$466.87
|
| Rate for Payer: Networks By Design Commercial |
$404.62
|
| Rate for Payer: Prime Health Services Commercial |
$529.12
|
|
|
DACOMITINIB 15 MG TABLET [222938]
|
Facility
OP
|
$622.49
|
|
|
Service Code
|
NDC 0069-0197-30
|
| Hospital Charge Code |
ERX222938
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$124.50 |
| Max. Negotiated Rate |
$560.24 |
| Rate for Payer: Aetna of CA HMO/PPO |
$378.04
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$529.12
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$342.37
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$342.37
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$301.41
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$367.77
|
| Rate for Payer: BCBS Transplant Transplant |
$373.49
|
| Rate for Payer: Blue Shield of California Commercial |
$391.55
|
| Rate for Payer: Blue Shield of California EPN |
$304.40
|
| Rate for Payer: Cash Price |
$280.12
|
| Rate for Payer: Central Health Plan Commercial |
$497.99
|
| Rate for Payer: Cigna of CA HMO |
$435.74
|
| Rate for Payer: Cigna of CA PPO |
$435.74
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$529.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$249.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$249.00
|
| Rate for Payer: Galaxy Health WC |
$529.12
|
| Rate for Payer: Global Benefits Group Commercial |
$373.49
|
| Rate for Payer: Health Management Network EPO/PPO |
$560.24
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$466.87
|
| Rate for Payer: IEHP medi-cal |
$217.87
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$415.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$124.50
|
| Rate for Payer: Multiplan Commercial |
$466.87
|
| Rate for Payer: Networks By Design Commercial |
$404.62
|
| Rate for Payer: Prime Health Services Commercial |
$529.12
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$373.49
|
| Rate for Payer: Riverside University Health MISP |
$249.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$373.49
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$373.49
|
| Rate for Payer: United Healthcare All Other Commercial |
$311.24
|
| Rate for Payer: United Healthcare All Other HMO |
$311.24
|
| Rate for Payer: United Healthcare HMO Rider |
$311.24
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$311.24
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$529.12
|
| Rate for Payer: Vantage Medical Group Senior |
$529.12
|
|
|
DACOMITINIB 30 MG TABLET [222939]
|
Facility
OP
|
$622.49
|
|
|
Service Code
|
NDC 0069-1198-30
|
| Hospital Charge Code |
ERX222939
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$124.50 |
| Max. Negotiated Rate |
$560.24 |
| Rate for Payer: Aetna of CA HMO/PPO |
$378.04
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$529.12
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$342.37
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$342.37
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$301.41
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$367.77
|
| Rate for Payer: BCBS Transplant Transplant |
$373.49
|
| Rate for Payer: Blue Shield of California Commercial |
$391.55
|
| Rate for Payer: Blue Shield of California EPN |
$304.40
|
| Rate for Payer: Cash Price |
$280.12
|
| Rate for Payer: Central Health Plan Commercial |
$497.99
|
| Rate for Payer: Cigna of CA HMO |
$435.74
|
| Rate for Payer: Cigna of CA PPO |
$435.74
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$529.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$249.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$249.00
|
| Rate for Payer: Galaxy Health WC |
$529.12
|
| Rate for Payer: Global Benefits Group Commercial |
$373.49
|
| Rate for Payer: Health Management Network EPO/PPO |
$560.24
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$466.87
|
| Rate for Payer: IEHP medi-cal |
$217.87
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$415.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$124.50
|
| Rate for Payer: Multiplan Commercial |
$466.87
|
| Rate for Payer: Networks By Design Commercial |
$404.62
|
| Rate for Payer: Prime Health Services Commercial |
$529.12
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$373.49
|
| Rate for Payer: Riverside University Health MISP |
$249.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$373.49
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$373.49
|
| Rate for Payer: United Healthcare All Other Commercial |
$311.24
|
| Rate for Payer: United Healthcare All Other HMO |
$311.24
|
| Rate for Payer: United Healthcare HMO Rider |
$311.24
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$311.24
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$529.12
|
| Rate for Payer: Vantage Medical Group Senior |
$529.12
|
|
|
DACOMITINIB 30 MG TABLET [222939]
|
Facility
IP
|
$622.49
|
|
|
Service Code
|
NDC 0069-1198-30
|
| Hospital Charge Code |
ERX222939
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$124.50 |
| Max. Negotiated Rate |
$560.24 |
| Rate for Payer: Blue Shield of California Commercial |
$466.87
|
| Rate for Payer: Blue Shield of California EPN |
$332.41
|
| Rate for Payer: Cash Price |
$280.12
|
| Rate for Payer: Central Health Plan Commercial |
$497.99
|
| Rate for Payer: Cigna of CA HMO |
$435.74
|
| Rate for Payer: Cigna of CA PPO |
$435.74
|
| Rate for Payer: EPIC Health Plan Commercial |
$249.00
|
| Rate for Payer: Galaxy Health WC |
$529.12
|
| Rate for Payer: Global Benefits Group Commercial |
$373.49
|
| Rate for Payer: Health Management Network EPO/PPO |
$560.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$415.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$124.50
|
| Rate for Payer: Multiplan Commercial |
$466.87
|
| Rate for Payer: Networks By Design Commercial |
$404.62
|
| Rate for Payer: Prime Health Services Commercial |
$529.12
|
|
