|
Application of skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area
|
Facility
OP
|
$397,400.00
|
|
|
Service Code
|
CPT 15271
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,278.49 |
| Max. Negotiated Rate |
$397,400.00 |
| Rate for Payer: Adventist Health Medi-Cal |
$2,278.49
|
| Rate for Payer: Aetna of CA HMO/PPO |
$6,248.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3,417.74
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2,506.34
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2,278.49
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$397,400.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,846.00
|
| Rate for Payer: Blue Shield of California Commercial |
$4,121.55
|
| Rate for Payer: Blue Shield of California EPN |
$2,960.28
|
| Rate for Payer: Caremore Medicare Advantage |
$2,278.49
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,417.74
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,075.96
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$2,278.49
|
| Rate for Payer: EPIC Health Plan Transplant |
$2,278.49
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$3,736.72
|
| Rate for Payer: IEHP medi-cal |
$3,759.51
|
| Rate for Payer: IEHP Medicare Advantage |
$2,278.49
|
| Rate for Payer: Innovage PACE Commercial |
$3,417.74
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,278.49
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3,053.18
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3,053.18
|
| Rate for Payer: Prime Health Services Medicare |
$2,415.20
|
| Rate for Payer: Riverside University Health MISP |
$2,506.34
|
| Rate for Payer: United Healthcare All Other Commercial |
$5,893.00
|
| Rate for Payer: United Healthcare All Other HMO |
$7,027.00
|
| Rate for Payer: United Healthcare HMO Rider |
$4,217.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3,918.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,417.74
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,506.34
|
| Rate for Payer: Vantage Medical Group Senior |
$2,278.49
|
|
|
APRACLONIDINE 0.5 % EYE DROPS [9119]
|
Facility
OP
|
$15.42
|
|
|
Service Code
|
NDC 61314-665-05
|
| Hospital Charge Code |
1740300
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.08 |
| Max. Negotiated Rate |
$13.88 |
| Rate for Payer: Aetna of CA HMO/PPO |
$9.36
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$13.11
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$8.48
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$8.48
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$7.47
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9.11
|
| Rate for Payer: BCBS Transplant Transplant |
$9.25
|
| Rate for Payer: Blue Shield of California Commercial |
$9.70
|
| Rate for Payer: Blue Shield of California EPN |
$7.54
|
| Rate for Payer: Cash Price |
$6.94
|
| Rate for Payer: Central Health Plan Commercial |
$12.34
|
| Rate for Payer: Cigna of CA HMO |
$10.79
|
| Rate for Payer: Cigna of CA PPO |
$10.79
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$13.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.17
|
| Rate for Payer: EPIC Health Plan Transplant |
$6.17
|
| Rate for Payer: Galaxy Health WC |
$13.11
|
| Rate for Payer: Global Benefits Group Commercial |
$9.25
|
| Rate for Payer: Health Management Network EPO/PPO |
$13.88
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$11.56
|
| Rate for Payer: IEHP medi-cal |
$5.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$10.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.08
|
| Rate for Payer: Multiplan Commercial |
$11.56
|
| Rate for Payer: Networks By Design Commercial |
$10.02
|
| Rate for Payer: Prime Health Services Commercial |
$13.11
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$9.25
|
| Rate for Payer: Riverside University Health MISP |
$6.17
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$9.25
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$9.25
|
| Rate for Payer: United Healthcare All Other Commercial |
$7.71
|
| Rate for Payer: United Healthcare All Other HMO |
$7.71
|
| Rate for Payer: United Healthcare HMO Rider |
$7.71
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$7.71
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$13.11
|
| Rate for Payer: Vantage Medical Group Senior |
$13.11
|
|
|
APRACLONIDINE 0.5 % EYE DROPS [9119]
|
Facility
IP
|
$15.42
|
|
|
Service Code
|
NDC 61314-665-05
|
| Hospital Charge Code |
1740300
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.08 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$11.56
|
| Rate for Payer: Blue Shield of California EPN |
$8.23
|
| Rate for Payer: Cash Price |
$6.94
|
| Rate for Payer: Cash Price |
$6.94
|
| Rate for Payer: Central Health Plan Commercial |
$12.34
|
| Rate for Payer: Cigna of CA HMO |
$10.79
|
| Rate for Payer: Cigna of CA PPO |
$10.79
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.17
|
| Rate for Payer: Galaxy Health WC |
$13.11
|
| Rate for Payer: Global Benefits Group Commercial |
$9.25
|
| Rate for Payer: Health Management Network EPO/PPO |
$13.88
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$10.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.08
|
| Rate for Payer: Multiplan Commercial |
$11.56
|
| Rate for Payer: Networks By Design Commercial |
$10.02
|
| Rate for Payer: Prime Health Services Commercial |
$13.11
|
|
|
APREPITANT 7.2 MG/ML INTRAVENOUS EMULSION [220348]
|
Facility
OP
|
$28.00
|
|
|
Service Code
|
CPT J0185
|
| Hospital Charge Code |
NDG220348
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.73 |
| Max. Negotiated Rate |
$25.20 |
| Rate for Payer: Adventist Health Medi-Cal |
$1.73
|
| Rate for Payer: Aetna of CA HMO/PPO |
$10.74
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.16
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.90
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.90
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$4.87
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5.34
|
| Rate for Payer: BCBS Transplant Transplant |
$16.80
|
| Rate for Payer: Blue Shield of California Commercial |
$3.91
|
| Rate for Payer: Blue Shield of California EPN |
$3.55
|
| Rate for Payer: Caremore Medicare Advantage |
$1.73
|
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Central Health Plan Commercial |
$22.40
|
| Rate for Payer: Cigna of CA HMO |
$19.60
|
| Rate for Payer: Cigna of CA PPO |
$19.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.33
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$1.73
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.73
|
| Rate for Payer: Galaxy Health WC |
$23.80
|
| Rate for Payer: Global Benefits Group Commercial |
$16.80
|
| Rate for Payer: Health Management Network EPO/PPO |
$25.20
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$21.00
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$2.84
|
| Rate for Payer: IEHP medi-cal |
$2.85
|
| Rate for Payer: IEHP Medicare Advantage |
$1.73
|
| Rate for Payer: Innovage PACE Commercial |
$2.59
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$18.68
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.60
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.32
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.32
|
| Rate for Payer: Multiplan Commercial |
$21.00
|
| Rate for Payer: Networks By Design Commercial |
$14.00
|
| Rate for Payer: Prime Health Services Commercial |
$23.80
|
| Rate for Payer: Prime Health Services Medicare |
$1.83
|
| Rate for Payer: Riverside University Health MISP |
$1.90
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$16.80
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$16.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$14.00
|
| Rate for Payer: United Healthcare All Other HMO |
$14.00
|
| Rate for Payer: United Healthcare HMO Rider |
$14.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$14.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.59
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.90
|
| Rate for Payer: Vantage Medical Group Senior |
$1.73
|
|
|
APREPITANT 7.2 MG/ML INTRAVENOUS EMULSION [220348]
|
Facility
IP
|
$28.00
|
|
|
Service Code
|
CPT J0185
|
| Hospital Charge Code |
NDG220348
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.60 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$21.00
|
| Rate for Payer: Blue Shield of California EPN |
$14.95
|
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Central Health Plan Commercial |
$22.40
|
| Rate for Payer: Cigna of CA HMO |
$19.60
|
| Rate for Payer: Cigna of CA PPO |
$19.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.20
|
| Rate for Payer: EPIC Health Plan Transplant |
$11.20
|
| Rate for Payer: Galaxy Health WC |
$23.80
|
| Rate for Payer: Global Benefits Group Commercial |
$16.80
|
| Rate for Payer: Health Management Network EPO/PPO |
$25.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$18.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.60
|
| Rate for Payer: Multiplan Commercial |
$21.00
|
| Rate for Payer: Networks By Design Commercial |
$14.00
|
| Rate for Payer: Prime Health Services Commercial |
$23.80
|
|
|
Aqueous shunt to extraocular equatorial plate reservoir, external approach; with graft
|
Facility
OP
|
$25,512.00
|
|
|
Service Code
|
CPT 66180
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4,755.97 |
| Max. Negotiated Rate |
$25,512.00 |
| Rate for Payer: Adventist Health Medi-Cal |
$5,080.00
|
| Rate for Payer: Aetna of CA HMO/PPO |
$11,071.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$7,620.00
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$5,588.00
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$5,080.00
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$6,419.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7,830.00
|
| Rate for Payer: Blue Shield of California Commercial |
$6,621.66
|
| Rate for Payer: Blue Shield of California EPN |
$4,755.97
|
| Rate for Payer: Caremore Medicare Advantage |
$5,080.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7,620.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$6,858.00
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$5,080.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$5,080.00
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$8,331.20
|
| Rate for Payer: IEHP medi-cal |
$8,382.00
|
| Rate for Payer: IEHP Medicare Advantage |
$5,080.00
|
| Rate for Payer: Innovage PACE Commercial |
$7,620.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5,080.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$6,807.20
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$6,807.20
|
| Rate for Payer: Prime Health Services Medicare |
$5,384.80
|
| Rate for Payer: Riverside University Health MISP |
$5,588.00
|
| 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 |
$7,620.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5,588.00
|
| Rate for Payer: Vantage Medical Group Senior |
$5,080.00
|
|
|
Aqueous shunt to extraocular equatorial plate reservoir, external approach; without graft
|
Facility
OP
|
$25,512.00
|
|
|
Service Code
|
CPT 66179
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,960.28 |
| Max. Negotiated Rate |
$25,512.00 |
| Rate for Payer: Adventist Health Medi-Cal |
$6,530.21
|
| Rate for Payer: Aetna of CA HMO/PPO |
$10,567.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$9,795.32
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$7,183.23
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$6,530.21
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$6,419.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7,830.00
|
| Rate for Payer: Blue Shield of California Commercial |
$4,121.55
|
| Rate for Payer: Blue Shield of California EPN |
$2,960.28
|
| Rate for Payer: Caremore Medicare Advantage |
$6,530.21
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9,795.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$8,815.78
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$6,530.21
|
| Rate for Payer: EPIC Health Plan Transplant |
$6,530.21
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$10,709.54
|
| Rate for Payer: IEHP medi-cal |
$10,774.85
|
| Rate for Payer: IEHP Medicare Advantage |
$6,530.21
|
| Rate for Payer: Innovage PACE Commercial |
$9,795.32
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$6,530.21
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$8,750.48
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$8,750.48
|
| Rate for Payer: Prime Health Services Medicare |
$6,922.02
|
| Rate for Payer: Riverside University Health MISP |
$7,183.23
|
| 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 |
$9,795.32
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7,183.23
|
| Rate for Payer: Vantage Medical Group Senior |
$6,530.21
|
|
|
ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION [77581]
|
Facility
OP
|
$2.50
|
|
|
Service Code
|
NDC 62756-277-02
|
| Hospital Charge Code |
1744128
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.50 |
| Max. Negotiated Rate |
$2.25 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.52
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.12
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.38
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.38
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1.21
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.48
|
| Rate for Payer: BCBS Transplant Transplant |
$1.50
|
| Rate for Payer: Blue Shield of California Commercial |
$1.57
|
| Rate for Payer: Blue Shield of California EPN |
$1.22
|
| Rate for Payer: Cash Price |
$1.13
|
| Rate for Payer: Central Health Plan Commercial |
$2.00
|
| Rate for Payer: Cigna of CA HMO |
$1.75
|
| Rate for Payer: Cigna of CA PPO |
$1.75
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.00
|
| Rate for Payer: Galaxy Health WC |
$2.12
|
| Rate for Payer: Global Benefits Group Commercial |
$1.50
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.25
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1.88
|
| Rate for Payer: IEHP medi-cal |
$0.88
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.50
|
| Rate for Payer: Multiplan Commercial |
$1.88
|
| Rate for Payer: Networks By Design Commercial |
$1.62
|
| Rate for Payer: Prime Health Services Commercial |
$2.12
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$1.50
|
| Rate for Payer: Riverside University Health MISP |
$1.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.50
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.50
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.25
|
| Rate for Payer: United Healthcare All Other HMO |
$1.25
|
| Rate for Payer: United Healthcare HMO Rider |
$1.25
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.12
|
| Rate for Payer: Vantage Medical Group Senior |
$2.12
|
|
|
ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION [77581]
|
Facility
IP
|
$2.50
|
|
|
Service Code
|
NDC 62756-277-01
|
| Hospital Charge Code |
1744128
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.50 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$1.88
|
| Rate for Payer: Blue Shield of California EPN |
$1.34
|
| Rate for Payer: Cash Price |
$1.13
|
| Rate for Payer: Cash Price |
$1.13
|
| Rate for Payer: Central Health Plan Commercial |
$2.00
|
| Rate for Payer: Cigna of CA HMO |
$1.75
|
| Rate for Payer: Cigna of CA PPO |
$1.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.00
|
| Rate for Payer: Galaxy Health WC |
$2.12
|
| Rate for Payer: Global Benefits Group Commercial |
$1.50
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.25
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.50
|
| Rate for Payer: Multiplan Commercial |
$1.88
|
| Rate for Payer: Networks By Design Commercial |
$1.62
|
| Rate for Payer: Prime Health Services Commercial |
$2.12
|
|
|
ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION [77581]
|
Facility
IP
|
$11.26
|
|
|
Service Code
|
NDC 63402-911-30
|
| Hospital Charge Code |
1744128
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.25 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$8.44
|
| Rate for Payer: Blue Shield of California EPN |
$6.01
|
| Rate for Payer: Cash Price |
$5.07
|
| Rate for Payer: Cash Price |
$5.07
|
| Rate for Payer: Central Health Plan Commercial |
$9.01
|
| Rate for Payer: Cigna of CA HMO |
$7.88
|
| Rate for Payer: Cigna of CA PPO |
$7.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.50
|
| Rate for Payer: Galaxy Health WC |
$9.57
|
| Rate for Payer: Global Benefits Group Commercial |
$6.76
|
| Rate for Payer: Health Management Network EPO/PPO |
$10.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$7.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.25
|
| Rate for Payer: Multiplan Commercial |
$8.44
|
| Rate for Payer: Networks By Design Commercial |
$7.32
|
| Rate for Payer: Prime Health Services Commercial |
$9.57
|
|
|
ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION [77581]
|
Facility
IP
|
$2.50
|
|
|
Service Code
|
NDC 62756-277-02
|
| Hospital Charge Code |
1744128
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.50 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$1.88
|
| Rate for Payer: Blue Shield of California EPN |
$1.34
|
| Rate for Payer: Cash Price |
$1.13
|
| Rate for Payer: Cash Price |
$1.13
|
| Rate for Payer: Central Health Plan Commercial |
$2.00
|
| Rate for Payer: Cigna of CA HMO |
$1.75
|
| Rate for Payer: Cigna of CA PPO |
$1.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.00
|
| Rate for Payer: Galaxy Health WC |
$2.12
|
| Rate for Payer: Global Benefits Group Commercial |
$1.50
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.25
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.50
|
| Rate for Payer: Multiplan Commercial |
$1.88
|
| Rate for Payer: Networks By Design Commercial |
$1.62
|
| Rate for Payer: Prime Health Services Commercial |
$2.12
|
|
|
ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION [77581]
|
Facility
OP
|
$3.85
|
|
|
Service Code
|
NDC 0093-5955-11
|
| Hospital Charge Code |
1744128
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.77 |
| Max. Negotiated Rate |
$3.46 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2.34
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3.27
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.12
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.12
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1.86
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.27
|
| Rate for Payer: BCBS Transplant Transplant |
$2.31
|
| Rate for Payer: Blue Shield of California Commercial |
$2.42
|
| Rate for Payer: Blue Shield of California EPN |
$1.88
|
| Rate for Payer: Cash Price |
$1.73
|
| Rate for Payer: Central Health Plan Commercial |
$3.08
|
| Rate for Payer: Cigna of CA HMO |
$2.70
|
| Rate for Payer: Cigna of CA PPO |
$2.70
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.54
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.54
|
| Rate for Payer: Galaxy Health WC |
$3.27
|
| Rate for Payer: Global Benefits Group Commercial |
$2.31
|
| Rate for Payer: Health Management Network EPO/PPO |
$3.46
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$2.89
|
| Rate for Payer: IEHP medi-cal |
$1.35
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.77
|
| Rate for Payer: Multiplan Commercial |
$2.89
|
| Rate for Payer: Networks By Design Commercial |
$2.50
|
| Rate for Payer: Prime Health Services Commercial |
$3.27
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$2.31
|
| Rate for Payer: Riverside University Health MISP |
$1.54
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.31
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.31
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.92
|
| Rate for Payer: United Healthcare All Other HMO |
$1.92
|
| Rate for Payer: United Healthcare HMO Rider |
$1.92
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.92
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.27
|
| Rate for Payer: Vantage Medical Group Senior |
$3.27
|
|
|
ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION [77581]
|
Facility
IP
|
$11.26
|
|
|
Service Code
|
NDC 63402-911-01
|
| Hospital Charge Code |
1744128
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.25 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$8.44
|
| Rate for Payer: Blue Shield of California EPN |
$6.01
|
| Rate for Payer: Cash Price |
$5.07
|
| Rate for Payer: Cash Price |
$5.07
|
| Rate for Payer: Central Health Plan Commercial |
$9.01
|
| Rate for Payer: Cigna of CA HMO |
$7.88
|
| Rate for Payer: Cigna of CA PPO |
$7.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.50
|
| Rate for Payer: Galaxy Health WC |
$9.57
|
| Rate for Payer: Global Benefits Group Commercial |
$6.76
|
| Rate for Payer: Health Management Network EPO/PPO |
$10.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$7.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.25
|
| Rate for Payer: Multiplan Commercial |
$8.44
|
| Rate for Payer: Networks By Design Commercial |
$7.32
|
| Rate for Payer: Prime Health Services Commercial |
$9.57
|
|
|
ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION [77581]
|
Facility
IP
|
$3.85
|
|
|
Service Code
|
NDC 0093-5955-56
|
| Hospital Charge Code |
1744128
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.77 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$2.89
|
| Rate for Payer: Blue Shield of California EPN |
$2.06
|
| Rate for Payer: Cash Price |
$1.73
|
| Rate for Payer: Cash Price |
$1.73
|
| Rate for Payer: Central Health Plan Commercial |
$3.08
|
| Rate for Payer: Cigna of CA HMO |
$2.70
|
| Rate for Payer: Cigna of CA PPO |
$2.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.54
|
| Rate for Payer: Galaxy Health WC |
$3.27
|
| Rate for Payer: Global Benefits Group Commercial |
$2.31
|
| Rate for Payer: Health Management Network EPO/PPO |
$3.46
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.77
|
| Rate for Payer: Multiplan Commercial |
$2.89
|
| Rate for Payer: Networks By Design Commercial |
$2.50
|
| Rate for Payer: Prime Health Services Commercial |
$3.27
|
|
|
ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION [77581]
|
Facility
OP
|
$2.50
|
|
|
Service Code
|
NDC 62756-277-01
|
| Hospital Charge Code |
1744128
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.50 |
| Max. Negotiated Rate |
$2.25 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.52
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.12
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.38
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.38
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1.21
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.48
|
| Rate for Payer: BCBS Transplant Transplant |
$1.50
|
| Rate for Payer: Blue Shield of California Commercial |
$1.57
|
| Rate for Payer: Blue Shield of California EPN |
$1.22
|
| Rate for Payer: Cash Price |
$1.13
|
| Rate for Payer: Central Health Plan Commercial |
$2.00
|
| Rate for Payer: Cigna of CA HMO |
$1.75
|
| Rate for Payer: Cigna of CA PPO |
$1.75
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.00
|
| Rate for Payer: Galaxy Health WC |
$2.12
|
| Rate for Payer: Global Benefits Group Commercial |
$1.50
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.25
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1.88
|
| Rate for Payer: IEHP medi-cal |
$0.88
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.50
|
| Rate for Payer: Multiplan Commercial |
$1.88
|
| Rate for Payer: Networks By Design Commercial |
$1.62
|
| Rate for Payer: Prime Health Services Commercial |
$2.12
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$1.50
|
| Rate for Payer: Riverside University Health MISP |
$1.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.50
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.50
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.25
|
| Rate for Payer: United Healthcare All Other HMO |
$1.25
|
| Rate for Payer: United Healthcare HMO Rider |
$1.25
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.12
|
| Rate for Payer: Vantage Medical Group Senior |
$2.12
|
|
|
ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION [77581]
|
Facility
IP
|
$3.85
|
|
|
Service Code
|
NDC 0093-5955-11
|
| Hospital Charge Code |
1744128
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.77 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$2.89
|
| Rate for Payer: Blue Shield of California EPN |
$2.06
|
| Rate for Payer: Cash Price |
$1.73
|
| Rate for Payer: Cash Price |
$1.73
|
| Rate for Payer: Central Health Plan Commercial |
$3.08
|
| Rate for Payer: Cigna of CA HMO |
$2.70
|
| Rate for Payer: Cigna of CA PPO |
$2.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.54
|
| Rate for Payer: Galaxy Health WC |
$3.27
|
| Rate for Payer: Global Benefits Group Commercial |
$2.31
|
| Rate for Payer: Health Management Network EPO/PPO |
$3.46
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.77
|
| Rate for Payer: Multiplan Commercial |
$2.89
|
| Rate for Payer: Networks By Design Commercial |
$2.50
|
| Rate for Payer: Prime Health Services Commercial |
$3.27
|
|
|
ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION [77581]
|
Facility
OP
|
$11.26
|
|
|
Service Code
|
NDC 63402-911-64
|
| Hospital Charge Code |
1744128
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.25 |
| Max. Negotiated Rate |
$10.13 |
| Rate for Payer: Aetna of CA HMO/PPO |
$6.84
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$9.57
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$6.19
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$6.19
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$5.45
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6.65
|
| Rate for Payer: BCBS Transplant Transplant |
$6.76
|
| Rate for Payer: Blue Shield of California Commercial |
$7.08
|
| Rate for Payer: Blue Shield of California EPN |
$5.51
|
| Rate for Payer: Cash Price |
$5.07
|
| Rate for Payer: Central Health Plan Commercial |
$9.01
|
| Rate for Payer: Cigna of CA HMO |
$7.88
|
| Rate for Payer: Cigna of CA PPO |
$7.88
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.50
|
| Rate for Payer: EPIC Health Plan Transplant |
$4.50
|
| Rate for Payer: Galaxy Health WC |
$9.57
|
| Rate for Payer: Global Benefits Group Commercial |
$6.76
|
| Rate for Payer: Health Management Network EPO/PPO |
$10.13
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$8.44
|
| Rate for Payer: IEHP medi-cal |
$3.94
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$7.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.25
|
| Rate for Payer: Multiplan Commercial |
$8.44
|
| Rate for Payer: Networks By Design Commercial |
$7.32
|
| Rate for Payer: Prime Health Services Commercial |
$9.57
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$6.76
|
| Rate for Payer: Riverside University Health MISP |
$4.50
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$6.76
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$6.76
|
| Rate for Payer: United Healthcare All Other Commercial |
$5.63
|
| Rate for Payer: United Healthcare All Other HMO |
$5.63
|
| Rate for Payer: United Healthcare HMO Rider |
$5.63
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$5.63
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.57
|
| Rate for Payer: Vantage Medical Group Senior |
$9.57
|
|
|
ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION [77581]
|
Facility
OP
|
$3.85
|
|
|
Service Code
|
NDC 0093-5955-06
|
| Hospital Charge Code |
1744128
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.77 |
| Max. Negotiated Rate |
$3.46 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2.34
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3.27
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.12
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.12
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1.86
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.27
|
| Rate for Payer: BCBS Transplant Transplant |
$2.31
|
| Rate for Payer: Blue Shield of California Commercial |
$2.42
|
| Rate for Payer: Blue Shield of California EPN |
$1.88
|
| Rate for Payer: Cash Price |
$1.73
|
| Rate for Payer: Central Health Plan Commercial |
$3.08
|
| Rate for Payer: Cigna of CA HMO |
$2.70
|
| Rate for Payer: Cigna of CA PPO |
$2.70
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.54
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.54
|
| Rate for Payer: Galaxy Health WC |
$3.27
|
| Rate for Payer: Global Benefits Group Commercial |
$2.31
|
| Rate for Payer: Health Management Network EPO/PPO |
$3.46
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$2.89
|
| Rate for Payer: IEHP medi-cal |
$1.35
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.77
|
| Rate for Payer: Multiplan Commercial |
$2.89
|
| Rate for Payer: Networks By Design Commercial |
$2.50
|
| Rate for Payer: Prime Health Services Commercial |
$3.27
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$2.31
|
| Rate for Payer: Riverside University Health MISP |
$1.54
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.31
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.31
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.92
|
| Rate for Payer: United Healthcare All Other HMO |
$1.92
|
| Rate for Payer: United Healthcare HMO Rider |
$1.92
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.92
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.27
|
| Rate for Payer: Vantage Medical Group Senior |
$3.27
|
|
|
ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION [77581]
|
Facility
OP
|
$11.26
|
|
|
Service Code
|
NDC 63402-911-01
|
| Hospital Charge Code |
1744128
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.25 |
| Max. Negotiated Rate |
$10.13 |
| Rate for Payer: Aetna of CA HMO/PPO |
$6.84
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$9.57
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$6.19
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$6.19
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$5.45
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6.65
|
| Rate for Payer: BCBS Transplant Transplant |
$6.76
|
| Rate for Payer: Blue Shield of California Commercial |
$7.08
|
| Rate for Payer: Blue Shield of California EPN |
$5.51
|
| Rate for Payer: Cash Price |
$5.07
|
| Rate for Payer: Central Health Plan Commercial |
$9.01
|
| Rate for Payer: Cigna of CA HMO |
$7.88
|
| Rate for Payer: Cigna of CA PPO |
$7.88
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.50
|
| Rate for Payer: EPIC Health Plan Transplant |
$4.50
|
| Rate for Payer: Galaxy Health WC |
$9.57
|
| Rate for Payer: Global Benefits Group Commercial |
$6.76
|
| Rate for Payer: Health Management Network EPO/PPO |
$10.13
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$8.44
|
| Rate for Payer: IEHP medi-cal |
$3.94
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$7.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.25
|
| Rate for Payer: Multiplan Commercial |
$8.44
|
| Rate for Payer: Networks By Design Commercial |
$7.32
|
| Rate for Payer: Prime Health Services Commercial |
$9.57
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$6.76
|
| Rate for Payer: Riverside University Health MISP |
$4.50
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$6.76
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$6.76
|
| Rate for Payer: United Healthcare All Other Commercial |
$5.63
|
| Rate for Payer: United Healthcare All Other HMO |
$5.63
|
| Rate for Payer: United Healthcare HMO Rider |
$5.63
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$5.63
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.57
|
| Rate for Payer: Vantage Medical Group Senior |
$9.57
|
|
|
ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION [77581]
|
Facility
IP
|
$3.85
|
|
|
Service Code
|
NDC 0093-5955-06
|
| Hospital Charge Code |
1744128
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.77 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Cigna of CA PPO |
$2.70
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$2.89
|
| Rate for Payer: Blue Shield of California EPN |
$2.06
|
| Rate for Payer: Cash Price |
$1.73
|
| Rate for Payer: Cash Price |
$1.73
|
| Rate for Payer: Central Health Plan Commercial |
$3.08
|
| Rate for Payer: Cigna of CA HMO |
$2.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.54
|
| Rate for Payer: Galaxy Health WC |
$3.27
|
| Rate for Payer: Global Benefits Group Commercial |
$2.31
|
| Rate for Payer: Health Management Network EPO/PPO |
$3.46
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.77
|
| Rate for Payer: Multiplan Commercial |
$2.89
|
| Rate for Payer: Networks By Design Commercial |
$2.50
|
| Rate for Payer: Prime Health Services Commercial |
$3.27
|
|
|
ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION [77581]
|
Facility
IP
|
$11.26
|
|
|
Service Code
|
NDC 63402-911-64
|
| Hospital Charge Code |
1744128
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.25 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$8.44
|
| Rate for Payer: Blue Shield of California EPN |
$6.01
|
| Rate for Payer: Cash Price |
$5.07
|
| Rate for Payer: Cash Price |
$5.07
|
| Rate for Payer: Central Health Plan Commercial |
$9.01
|
| Rate for Payer: Cigna of CA HMO |
$7.88
|
| Rate for Payer: Cigna of CA PPO |
$7.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.50
|
| Rate for Payer: Galaxy Health WC |
$9.57
|
| Rate for Payer: Global Benefits Group Commercial |
$6.76
|
| Rate for Payer: Health Management Network EPO/PPO |
$10.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$7.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.25
|
| Rate for Payer: Multiplan Commercial |
$8.44
|
| Rate for Payer: Networks By Design Commercial |
$7.32
|
| Rate for Payer: Prime Health Services Commercial |
$9.57
|
|
|
ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION [77581]
|
Facility
OP
|
$11.26
|
|
|
Service Code
|
NDC 63402-911-30
|
| Hospital Charge Code |
1744128
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.25 |
| Max. Negotiated Rate |
$10.13 |
| Rate for Payer: Aetna of CA HMO/PPO |
$6.84
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$9.57
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$6.19
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$6.19
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$5.45
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6.65
|
| Rate for Payer: BCBS Transplant Transplant |
$6.76
|
| Rate for Payer: Blue Shield of California Commercial |
$7.08
|
| Rate for Payer: Blue Shield of California EPN |
$5.51
|
| Rate for Payer: Cash Price |
$5.07
|
| Rate for Payer: Central Health Plan Commercial |
$9.01
|
| Rate for Payer: Cigna of CA HMO |
$7.88
|
| Rate for Payer: Cigna of CA PPO |
$7.88
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.50
|
| Rate for Payer: EPIC Health Plan Transplant |
$4.50
|
| Rate for Payer: Galaxy Health WC |
$9.57
|
| Rate for Payer: Global Benefits Group Commercial |
$6.76
|
| Rate for Payer: Health Management Network EPO/PPO |
$10.13
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$8.44
|
| Rate for Payer: IEHP medi-cal |
$3.94
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$7.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.25
|
| Rate for Payer: Multiplan Commercial |
$8.44
|
| Rate for Payer: Networks By Design Commercial |
$7.32
|
| Rate for Payer: Prime Health Services Commercial |
$9.57
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$6.76
|
| Rate for Payer: Riverside University Health MISP |
$4.50
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$6.76
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$6.76
|
| Rate for Payer: United Healthcare All Other Commercial |
$5.63
|
| Rate for Payer: United Healthcare All Other HMO |
$5.63
|
| Rate for Payer: United Healthcare HMO Rider |
$5.63
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$5.63
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.57
|
| Rate for Payer: Vantage Medical Group Senior |
$9.57
|
|
|
ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION [77581]
|
Facility
OP
|
$3.85
|
|
|
Service Code
|
NDC 0093-5955-56
|
| Hospital Charge Code |
1744128
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.77 |
| Max. Negotiated Rate |
$3.46 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2.34
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3.27
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.12
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.12
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1.86
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.27
|
| Rate for Payer: BCBS Transplant Transplant |
$2.31
|
| Rate for Payer: Blue Shield of California Commercial |
$2.42
|
| Rate for Payer: Blue Shield of California EPN |
$1.88
|
| Rate for Payer: Cash Price |
$1.73
|
| Rate for Payer: Central Health Plan Commercial |
$3.08
|
| Rate for Payer: Cigna of CA HMO |
$2.70
|
| Rate for Payer: Cigna of CA PPO |
$2.70
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.54
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.54
|
| Rate for Payer: Galaxy Health WC |
$3.27
|
| Rate for Payer: Global Benefits Group Commercial |
$2.31
|
| Rate for Payer: Health Management Network EPO/PPO |
$3.46
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$2.89
|
| Rate for Payer: IEHP medi-cal |
$1.35
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.77
|
| Rate for Payer: Multiplan Commercial |
$2.89
|
| Rate for Payer: Networks By Design Commercial |
$2.50
|
| Rate for Payer: Prime Health Services Commercial |
$3.27
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$2.31
|
| Rate for Payer: Riverside University Health MISP |
$1.54
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.31
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.31
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.92
|
| Rate for Payer: United Healthcare All Other HMO |
$1.92
|
| Rate for Payer: United Healthcare HMO Rider |
$1.92
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.92
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.27
|
| Rate for Payer: Vantage Medical Group Senior |
$3.27
|
|
|
ARGATROBAN 100 MG/ML INTRAVENOUS SOLUTION [28947]
|
Facility
OP
|
$130.41
|
|
|
Service Code
|
CPT J0883
|
| Hospital Charge Code |
1759990
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.22 |
| Max. Negotiated Rate |
$117.37 |
| Rate for Payer: Adventist Health Medi-Cal |
$1.22
|
| Rate for Payer: Adventist Health Medi-Cal |
$1.22
|
| Rate for Payer: Aetna of CA HMO/PPO |
$21.41
|
| Rate for Payer: Aetna of CA HMO/PPO |
$21.41
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.52
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.52
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.34
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.34
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.34
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.34
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$8.98
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$8.98
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9.83
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9.83
|
| Rate for Payer: BCBS Transplant Transplant |
$146.88
|
| Rate for Payer: BCBS Transplant Transplant |
$78.25
|
| Rate for Payer: Blue Shield of California Commercial |
$4.28
|
| Rate for Payer: Blue Shield of California Commercial |
$4.28
|
| Rate for Payer: Blue Shield of California EPN |
$3.89
|
| Rate for Payer: Blue Shield of California EPN |
$3.89
|
| Rate for Payer: Caremore Medicare Advantage |
$1.22
|
| Rate for Payer: Caremore Medicare Advantage |
$1.22
|
| Rate for Payer: Cash Price |
$110.16
|
| Rate for Payer: Cash Price |
$58.68
|
| Rate for Payer: Cash Price |
$110.16
|
| Rate for Payer: Cash Price |
$58.68
|
| Rate for Payer: Central Health Plan Commercial |
$195.84
|
| Rate for Payer: Central Health Plan Commercial |
$104.33
|
| Rate for Payer: Cigna of CA HMO |
$91.29
|
| Rate for Payer: Cigna of CA HMO |
$171.36
|
| Rate for Payer: Cigna of CA PPO |
$171.36
|
| Rate for Payer: Cigna of CA PPO |
$91.29
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.83
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.83
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.64
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$1.22
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$1.22
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.22
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.22
|
| Rate for Payer: Galaxy Health WC |
$208.08
|
| Rate for Payer: Galaxy Health WC |
$110.85
|
| Rate for Payer: Global Benefits Group Commercial |
$146.88
|
| Rate for Payer: Global Benefits Group Commercial |
$78.25
|
| Rate for Payer: Health Management Network EPO/PPO |
$117.37
|
| Rate for Payer: Health Management Network EPO/PPO |
$220.32
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$183.60
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$97.81
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$2.00
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$2.00
|
| Rate for Payer: IEHP medi-cal |
$2.01
|
| Rate for Payer: IEHP medi-cal |
$2.01
|
| Rate for Payer: IEHP Medicare Advantage |
$1.22
|
| Rate for Payer: IEHP Medicare Advantage |
$1.22
|
| Rate for Payer: Innovage PACE Commercial |
$1.83
|
| Rate for Payer: Innovage PACE Commercial |
$1.83
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$163.28
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$86.98
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.22
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$48.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$26.08
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.63
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.63
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.63
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.63
|
| Rate for Payer: Multiplan Commercial |
$183.60
|
| Rate for Payer: Multiplan Commercial |
$97.81
|
| Rate for Payer: Networks By Design Commercial |
$65.20
|
| Rate for Payer: Networks By Design Commercial |
$122.40
|
| Rate for Payer: Prime Health Services Commercial |
$208.08
|
| Rate for Payer: Prime Health Services Commercial |
$110.85
|
| Rate for Payer: Prime Health Services Medicare |
$1.29
|
| Rate for Payer: Prime Health Services Medicare |
$1.29
|
| Rate for Payer: Riverside University Health MISP |
$1.34
|
| Rate for Payer: Riverside University Health MISP |
$1.34
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$78.25
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$146.88
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$146.88
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$78.25
|
| Rate for Payer: United Healthcare All Other Commercial |
$65.20
|
| Rate for Payer: United Healthcare All Other Commercial |
$122.40
|
| Rate for Payer: United Healthcare All Other HMO |
$122.40
|
| Rate for Payer: United Healthcare All Other HMO |
$65.20
|
| Rate for Payer: United Healthcare HMO Rider |
$122.40
|
| Rate for Payer: United Healthcare HMO Rider |
$65.20
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$65.20
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$122.40
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.83
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.83
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.34
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.34
|
| Rate for Payer: Vantage Medical Group Senior |
$1.22
|
| Rate for Payer: Vantage Medical Group Senior |
$1.22
|
|
|
ARGATROBAN 100 MG/ML INTRAVENOUS SOLUTION [28947]
|
Facility
IP
|
$244.80
|
|
|
Service Code
|
CPT J0883
|
| Hospital Charge Code |
1759990
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$48.96 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$97.81
|
| Rate for Payer: Blue Shield of California Commercial |
$183.60
|
| Rate for Payer: Blue Shield of California EPN |
$69.64
|
| Rate for Payer: Blue Shield of California EPN |
$130.72
|
| Rate for Payer: Cash Price |
$58.68
|
| Rate for Payer: Cash Price |
$58.68
|
| Rate for Payer: Cash Price |
$110.16
|
| Rate for Payer: Cash Price |
$110.16
|
| Rate for Payer: Central Health Plan Commercial |
$104.33
|
| Rate for Payer: Central Health Plan Commercial |
$195.84
|
| Rate for Payer: Cigna of CA HMO |
$171.36
|
| Rate for Payer: Cigna of CA HMO |
$91.29
|
| Rate for Payer: Cigna of CA PPO |
$91.29
|
| Rate for Payer: Cigna of CA PPO |
$171.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$52.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$97.92
|
| Rate for Payer: EPIC Health Plan Transplant |
$97.92
|
| Rate for Payer: EPIC Health Plan Transplant |
$52.16
|
| Rate for Payer: Galaxy Health WC |
$110.85
|
| Rate for Payer: Galaxy Health WC |
$208.08
|
| Rate for Payer: Global Benefits Group Commercial |
$146.88
|
| Rate for Payer: Global Benefits Group Commercial |
$78.25
|
| Rate for Payer: Health Management Network EPO/PPO |
$220.32
|
| Rate for Payer: Health Management Network EPO/PPO |
$117.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$86.98
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$163.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$26.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$48.96
|
| Rate for Payer: Multiplan Commercial |
$183.60
|
| Rate for Payer: Multiplan Commercial |
$97.81
|
| Rate for Payer: Networks By Design Commercial |
$65.20
|
| Rate for Payer: Networks By Design Commercial |
$122.40
|
| Rate for Payer: Prime Health Services Commercial |
$208.08
|
| Rate for Payer: Prime Health Services Commercial |
$110.85
|
|
