|
FOSAPREPITANT 150 MG INTRAVENOUS POWDER FOR SOLUTION [106783]
|
Facility
|
OP
|
$401.56
|
|
|
Service Code
|
NDC 0006-3061-00
|
| Hospital Charge Code |
1755762
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$80.31 |
| Max. Negotiated Rate |
$361.40 |
| Rate for Payer: Aetna of CA HMO/PPO |
$243.87
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$341.33
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$220.86
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$220.86
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$194.44
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$237.24
|
| Rate for Payer: Blue Distinction Transplant |
$240.94
|
| Rate for Payer: Blue Shield of California Commercial |
$252.58
|
| Rate for Payer: Blue Shield of California EPN |
$196.36
|
| Rate for Payer: Cash Price |
$180.70
|
| Rate for Payer: Central Health Plan Commercial |
$321.25
|
| Rate for Payer: Cigna of CA HMO |
$281.09
|
| Rate for Payer: Cigna of CA PPO |
$281.09
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$341.33
|
| Rate for Payer: Dignity Health Media |
$341.33
|
| Rate for Payer: Dignity Health Medi-Cal |
$341.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$160.62
|
| Rate for Payer: EPIC Health Plan Transplant |
$160.62
|
| Rate for Payer: Galaxy Health WC |
$341.33
|
| Rate for Payer: Global Benefits Group Commercial |
$240.94
|
| Rate for Payer: Health Management Network EPO/PPO |
$361.40
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$301.17
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$140.55
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$267.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$152.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$80.31
|
| Rate for Payer: Multiplan Commercial |
$301.17
|
| Rate for Payer: Networks By Design Commercial |
$200.78
|
| Rate for Payer: Prime Health Services Commercial |
$341.33
|
| Rate for Payer: Riverside University Health System MISP |
$160.62
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$240.94
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$240.94
|
| Rate for Payer: United Healthcare All Other Commercial |
$200.78
|
| Rate for Payer: United Healthcare All Other HMO |
$200.78
|
| Rate for Payer: United Healthcare HMO Rider |
$200.78
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$200.78
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$341.33
|
| Rate for Payer: Vantage Medical Group Senior |
$341.33
|
|
|
FOSAPREPITANT 150 MG INTRAVENOUS POWDER FOR SOLUTION [106783]
|
Facility
|
OP
|
$42.00
|
|
|
Service Code
|
NDC 71839-104-01
|
| Hospital Charge Code |
1755762
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.40 |
| Max. Negotiated Rate |
$37.80 |
| Rate for Payer: Aetna of CA HMO/PPO |
$25.51
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$35.70
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$23.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$23.10
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$20.34
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$24.81
|
| Rate for Payer: Blue Distinction Transplant |
$25.20
|
| Rate for Payer: Blue Shield of California Commercial |
$26.42
|
| Rate for Payer: Blue Shield of California EPN |
$20.54
|
| Rate for Payer: Cash Price |
$18.90
|
| Rate for Payer: Central Health Plan Commercial |
$33.60
|
| Rate for Payer: Cigna of CA HMO |
$29.40
|
| Rate for Payer: Cigna of CA PPO |
$29.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$35.70
|
| Rate for Payer: Dignity Health Media |
$35.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$35.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$16.80
|
| Rate for Payer: EPIC Health Plan Transplant |
$16.80
|
| Rate for Payer: Galaxy Health WC |
$35.70
|
| Rate for Payer: Global Benefits Group Commercial |
$25.20
|
| Rate for Payer: Health Management Network EPO/PPO |
$37.80
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$31.50
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$14.70
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$28.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$16.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.40
|
| Rate for Payer: Multiplan Commercial |
$31.50
|
| Rate for Payer: Networks By Design Commercial |
$21.00
|
| Rate for Payer: Prime Health Services Commercial |
$35.70
|
| Rate for Payer: Riverside University Health System MISP |
$16.80
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$25.20
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$25.20
|
| Rate for Payer: United Healthcare All Other Commercial |
$21.00
|
| Rate for Payer: United Healthcare All Other HMO |
$21.00
|
| Rate for Payer: United Healthcare HMO Rider |
$21.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$21.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$35.70
|
| Rate for Payer: Vantage Medical Group Senior |
$35.70
|
|
|
FOSAPREPITANT 150 MG INTRAVENOUS POWDER FOR SOLUTION [106783]
|
Facility
|
IP
|
$42.00
|
|
|
Service Code
|
NDC 71839-104-01
|
| Hospital Charge Code |
1755762
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.40 |
| Max. Negotiated Rate |
$37.80 |
| Rate for Payer: Blue Shield of California Commercial |
$31.50
|
| Rate for Payer: Blue Shield of California EPN |
$22.43
|
| Rate for Payer: Cash Price |
$18.90
|
| Rate for Payer: Central Health Plan Commercial |
$33.60
|
| Rate for Payer: Cigna of CA HMO |
$29.40
|
| Rate for Payer: Cigna of CA PPO |
$29.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$16.80
|
| Rate for Payer: EPIC Health Plan Transplant |
$16.80
|
| Rate for Payer: Galaxy Health WC |
$35.70
|
| Rate for Payer: Global Benefits Group Commercial |
$25.20
|
| Rate for Payer: Health Management Network EPO/PPO |
$37.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$28.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$16.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.40
|
| Rate for Payer: Multiplan Commercial |
$31.50
|
| Rate for Payer: Networks By Design Commercial |
$21.00
|
| Rate for Payer: Prime Health Services Commercial |
$35.70
|
| Rate for Payer: United Healthcare All Other Commercial |
$15.86
|
| Rate for Payer: United Healthcare All Other HMO |
$15.49
|
| Rate for Payer: United Healthcare HMO Rider |
$15.15
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$13.86
|
|
|
FOSAPREPITANT 150 MG INTRAVENOUS POWDER FOR SOLUTION [106783]
|
Facility
|
IP
|
$401.56
|
|
|
Service Code
|
NDC 0006-3061-01
|
| Hospital Charge Code |
1755762
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$80.31 |
| Max. Negotiated Rate |
$361.40 |
| Rate for Payer: Blue Shield of California Commercial |
$301.17
|
| Rate for Payer: Blue Shield of California EPN |
$214.43
|
| Rate for Payer: Cash Price |
$180.70
|
| Rate for Payer: Central Health Plan Commercial |
$321.25
|
| Rate for Payer: Cigna of CA HMO |
$281.09
|
| Rate for Payer: Cigna of CA PPO |
$281.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$160.62
|
| Rate for Payer: EPIC Health Plan Transplant |
$160.62
|
| Rate for Payer: Galaxy Health WC |
$341.33
|
| Rate for Payer: Global Benefits Group Commercial |
$240.94
|
| Rate for Payer: Health Management Network EPO/PPO |
$361.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$267.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$152.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$80.31
|
| Rate for Payer: Multiplan Commercial |
$301.17
|
| Rate for Payer: Networks By Design Commercial |
$200.78
|
| Rate for Payer: Prime Health Services Commercial |
$341.33
|
| Rate for Payer: United Healthcare All Other Commercial |
$151.63
|
| Rate for Payer: United Healthcare All Other HMO |
$148.10
|
| Rate for Payer: United Healthcare HMO Rider |
$144.88
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$132.51
|
|
|
FOSAPREPITANT 150 MG INTRAVENOUS POWDER FOR SOLUTION [106783]
|
Facility
|
OP
|
$401.56
|
|
|
Service Code
|
NDC 0006-3061-01
|
| Hospital Charge Code |
1755762
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$80.31 |
| Max. Negotiated Rate |
$361.40 |
| Rate for Payer: Aetna of CA HMO/PPO |
$243.87
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$341.33
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$220.86
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$220.86
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$194.44
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$237.24
|
| Rate for Payer: Blue Distinction Transplant |
$240.94
|
| Rate for Payer: Blue Shield of California Commercial |
$252.58
|
| Rate for Payer: Blue Shield of California EPN |
$196.36
|
| Rate for Payer: Cash Price |
$180.70
|
| Rate for Payer: Central Health Plan Commercial |
$321.25
|
| Rate for Payer: Cigna of CA HMO |
$281.09
|
| Rate for Payer: Cigna of CA PPO |
$281.09
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$341.33
|
| Rate for Payer: Dignity Health Media |
$341.33
|
| Rate for Payer: Dignity Health Medi-Cal |
$341.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$160.62
|
| Rate for Payer: EPIC Health Plan Transplant |
$160.62
|
| Rate for Payer: Galaxy Health WC |
$341.33
|
| Rate for Payer: Global Benefits Group Commercial |
$240.94
|
| Rate for Payer: Health Management Network EPO/PPO |
$361.40
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$301.17
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$140.55
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$267.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$152.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$80.31
|
| Rate for Payer: Multiplan Commercial |
$301.17
|
| Rate for Payer: Networks By Design Commercial |
$200.78
|
| Rate for Payer: Prime Health Services Commercial |
$341.33
|
| Rate for Payer: Riverside University Health System MISP |
$160.62
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$240.94
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$240.94
|
| Rate for Payer: United Healthcare All Other Commercial |
$200.78
|
| Rate for Payer: United Healthcare All Other HMO |
$200.78
|
| Rate for Payer: United Healthcare HMO Rider |
$200.78
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$200.78
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$341.33
|
| Rate for Payer: Vantage Medical Group Senior |
$341.33
|
|
|
FOSCARNET 24 MG/ML INTRAVENOUS SOLUTION [10093]
|
Facility
|
OP
|
$2.27
|
|
|
Service Code
|
CPT J1455
|
| Hospital Charge Code |
1754909
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.45 |
| Max. Negotiated Rate |
$481.53 |
| Rate for Payer: Adventist Health Medi-Cal |
$59.37
|
| Rate for Payer: Aetna of CA HMO/PPO |
$481.53
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$74.21
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$65.31
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$65.31
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$134.18
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$146.91
|
| Rate for Payer: Blue Distinction Transplant |
$1.36
|
| Rate for Payer: Blue Shield of California Commercial |
$104.01
|
| Rate for Payer: Blue Shield of California EPN |
$94.55
|
| Rate for Payer: Caremore Medicare Advantage |
$59.37
|
| Rate for Payer: Cash Price |
$1.02
|
| Rate for Payer: Cash Price |
$1.02
|
| Rate for Payer: Central Health Plan Commercial |
$1.82
|
| Rate for Payer: Cigna of CA HMO |
$1.59
|
| Rate for Payer: Cigna of CA PPO |
$1.59
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$89.05
|
| Rate for Payer: Dignity Health Media |
$59.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$65.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$80.15
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$59.37
|
| Rate for Payer: EPIC Health Plan Transplant |
$59.37
|
| Rate for Payer: Galaxy Health WC |
$1.93
|
| Rate for Payer: Global Benefits Group Commercial |
$1.36
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.04
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$1.70
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$97.37
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$97.96
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$59.37
|
| Rate for Payer: InnovAge PACE Commercial |
$89.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.51
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$140.33
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$59.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.45
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$79.55
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$79.55
|
| Rate for Payer: Multiplan Commercial |
$1.70
|
| Rate for Payer: Networks By Design Commercial |
$1.14
|
| Rate for Payer: Prime Health Services Commercial |
$1.93
|
| Rate for Payer: Prime Health Services Medicare |
$62.93
|
| Rate for Payer: Riverside University Health System MISP |
$65.31
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.36
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.36
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.14
|
| Rate for Payer: United Healthcare All Other HMO |
$1.14
|
| Rate for Payer: United Healthcare HMO Rider |
$1.14
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.14
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$89.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$65.31
|
| Rate for Payer: Vantage Medical Group Senior |
$59.37
|
|
|
FOSCARNET 24 MG/ML INTRAVENOUS SOLUTION [10093]
|
Facility
|
IP
|
$2.27
|
|
|
Service Code
|
CPT J1455
|
| Hospital Charge Code |
1754909
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.45 |
| Max. Negotiated Rate |
$2.04 |
| Rate for Payer: Blue Shield of California Commercial |
$1.70
|
| Rate for Payer: Blue Shield of California EPN |
$1.21
|
| Rate for Payer: Cash Price |
$1.02
|
| Rate for Payer: Central Health Plan Commercial |
$1.82
|
| Rate for Payer: Cigna of CA HMO |
$1.59
|
| Rate for Payer: Cigna of CA PPO |
$1.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.91
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.91
|
| Rate for Payer: Galaxy Health WC |
$1.93
|
| Rate for Payer: Global Benefits Group Commercial |
$1.36
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.51
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.45
|
| Rate for Payer: Multiplan Commercial |
$1.70
|
| Rate for Payer: Networks By Design Commercial |
$1.14
|
| Rate for Payer: Prime Health Services Commercial |
$1.93
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.86
|
| Rate for Payer: United Healthcare All Other HMO |
$0.84
|
| Rate for Payer: United Healthcare HMO Rider |
$0.82
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.75
|
|
|
FOSCARNET INTRAVITREAL INJECTION 2400 MCG/0.1 ML [4081568]
|
Facility
|
IP
|
$2.30
|
|
|
Service Code
|
CPT J1455
|
| Hospital Charge Code |
1754909
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.46 |
| Max. Negotiated Rate |
$2.07 |
| Rate for Payer: Blue Shield of California Commercial |
$1.72
|
| Rate for Payer: Blue Shield of California EPN |
$1.23
|
| Rate for Payer: Cash Price |
$1.04
|
| Rate for Payer: Central Health Plan Commercial |
$1.84
|
| Rate for Payer: Cigna of CA HMO |
$1.61
|
| Rate for Payer: Cigna of CA PPO |
$1.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.92
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.92
|
| Rate for Payer: Galaxy Health WC |
$1.96
|
| Rate for Payer: Global Benefits Group Commercial |
$1.38
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.53
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.46
|
| Rate for Payer: Multiplan Commercial |
$1.72
|
| Rate for Payer: Networks By Design Commercial |
$1.15
|
| Rate for Payer: Prime Health Services Commercial |
$1.96
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.87
|
| Rate for Payer: United Healthcare All Other HMO |
$0.85
|
| Rate for Payer: United Healthcare HMO Rider |
$0.83
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.76
|
|
|
FOSCARNET INTRAVITREAL INJECTION 2400 MCG/0.1 ML [4081568]
|
Facility
|
OP
|
$2.30
|
|
|
Service Code
|
CPT J1455
|
| Hospital Charge Code |
1754909
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.46 |
| Max. Negotiated Rate |
$481.53 |
| Rate for Payer: Adventist Health Medi-Cal |
$59.37
|
| Rate for Payer: Aetna of CA HMO/PPO |
$481.53
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$74.21
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$65.31
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$65.31
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$134.18
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$146.91
|
| Rate for Payer: Blue Distinction Transplant |
$1.38
|
| Rate for Payer: Blue Shield of California Commercial |
$104.01
|
| Rate for Payer: Blue Shield of California EPN |
$94.55
|
| Rate for Payer: Caremore Medicare Advantage |
$59.37
|
| Rate for Payer: Cash Price |
$1.04
|
| Rate for Payer: Cash Price |
$1.04
|
| Rate for Payer: Central Health Plan Commercial |
$1.84
|
| Rate for Payer: Cigna of CA HMO |
$1.61
|
| Rate for Payer: Cigna of CA PPO |
$1.61
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$89.05
|
| Rate for Payer: Dignity Health Media |
$59.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$65.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$80.15
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$59.37
|
| Rate for Payer: EPIC Health Plan Transplant |
$59.37
|
| Rate for Payer: Galaxy Health WC |
$1.96
|
| Rate for Payer: Global Benefits Group Commercial |
$1.38
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.07
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$1.72
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$97.37
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$97.96
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$59.37
|
| Rate for Payer: InnovAge PACE Commercial |
$89.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.53
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$140.33
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$59.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.46
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$79.55
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$79.55
|
| Rate for Payer: Multiplan Commercial |
$1.72
|
| Rate for Payer: Networks By Design Commercial |
$1.15
|
| Rate for Payer: Prime Health Services Commercial |
$1.96
|
| Rate for Payer: Prime Health Services Medicare |
$62.93
|
| Rate for Payer: Riverside University Health System MISP |
$65.31
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.38
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.38
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.15
|
| Rate for Payer: United Healthcare All Other HMO |
$1.15
|
| Rate for Payer: United Healthcare HMO Rider |
$1.15
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.15
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$89.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$65.31
|
| Rate for Payer: Vantage Medical Group Senior |
$59.37
|
|
|
FOSFOMYCIN TROMETHAMINE 3 GRAM ORAL PACKET [14825]
|
Facility
|
OP
|
$109.52
|
|
|
Service Code
|
NDC 0456-4300-08
|
| Hospital Charge Code |
ERX14825
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$21.90 |
| Max. Negotiated Rate |
$98.57 |
| Rate for Payer: Aetna of CA HMO/PPO |
$66.51
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$93.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$60.24
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$60.24
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$53.03
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$64.70
|
| Rate for Payer: Blue Distinction Transplant |
$65.71
|
| Rate for Payer: Blue Shield of California Commercial |
$68.89
|
| Rate for Payer: Blue Shield of California EPN |
$53.56
|
| Rate for Payer: Cash Price |
$49.28
|
| Rate for Payer: Central Health Plan Commercial |
$87.62
|
| Rate for Payer: Cigna of CA HMO |
$76.66
|
| Rate for Payer: Cigna of CA PPO |
$76.66
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$93.09
|
| Rate for Payer: Dignity Health Media |
$93.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$93.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$43.81
|
| Rate for Payer: EPIC Health Plan Transplant |
$43.81
|
| Rate for Payer: Galaxy Health WC |
$93.09
|
| Rate for Payer: Global Benefits Group Commercial |
$65.71
|
| Rate for Payer: Health Management Network EPO/PPO |
$98.57
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$82.14
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$38.33
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$73.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$41.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$21.90
|
| Rate for Payer: Multiplan Commercial |
$82.14
|
| Rate for Payer: Networks By Design Commercial |
$71.19
|
| Rate for Payer: Prime Health Services Commercial |
$93.09
|
| Rate for Payer: Riverside University Health System MISP |
$43.81
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$65.71
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$65.71
|
| Rate for Payer: United Healthcare All Other Commercial |
$54.76
|
| Rate for Payer: United Healthcare All Other HMO |
$54.76
|
| Rate for Payer: United Healthcare HMO Rider |
$54.76
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$54.76
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$93.09
|
| Rate for Payer: Vantage Medical Group Senior |
$93.09
|
|
|
FOSFOMYCIN TROMETHAMINE 3 GRAM ORAL PACKET [14825]
|
Facility
|
OP
|
$96.38
|
|
|
Service Code
|
NDC 70700-268-99
|
| Hospital Charge Code |
ERX14825
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$19.28 |
| Max. Negotiated Rate |
$86.74 |
| Rate for Payer: Aetna of CA HMO/PPO |
$58.53
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$81.92
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$53.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$53.01
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$46.67
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$56.94
|
| Rate for Payer: Blue Distinction Transplant |
$57.83
|
| Rate for Payer: Blue Shield of California Commercial |
$60.62
|
| Rate for Payer: Blue Shield of California EPN |
$47.13
|
| Rate for Payer: Cash Price |
$43.37
|
| Rate for Payer: Central Health Plan Commercial |
$77.10
|
| Rate for Payer: Cigna of CA HMO |
$67.47
|
| Rate for Payer: Cigna of CA PPO |
$67.47
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$81.92
|
| Rate for Payer: Dignity Health Media |
$81.92
|
| Rate for Payer: Dignity Health Medi-Cal |
$81.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$38.55
|
| Rate for Payer: EPIC Health Plan Transplant |
$38.55
|
| Rate for Payer: Galaxy Health WC |
$81.92
|
| Rate for Payer: Global Benefits Group Commercial |
$57.83
|
| Rate for Payer: Health Management Network EPO/PPO |
$86.74
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$72.28
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$33.73
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$64.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$36.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$19.28
|
| Rate for Payer: Multiplan Commercial |
$72.28
|
| Rate for Payer: Networks By Design Commercial |
$62.65
|
| Rate for Payer: Prime Health Services Commercial |
$81.92
|
| Rate for Payer: Riverside University Health System MISP |
$38.55
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$57.83
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$57.83
|
| Rate for Payer: United Healthcare All Other Commercial |
$48.19
|
| Rate for Payer: United Healthcare All Other HMO |
$48.19
|
| Rate for Payer: United Healthcare HMO Rider |
$48.19
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$48.19
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$81.92
|
| Rate for Payer: Vantage Medical Group Senior |
$81.92
|
|
|
FOSFOMYCIN TROMETHAMINE 3 GRAM ORAL PACKET [14825]
|
Facility
|
OP
|
$83.76
|
|
|
Service Code
|
NDC 67877-749-57
|
| Hospital Charge Code |
ERX14825
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$16.75 |
| Max. Negotiated Rate |
$75.38 |
| Rate for Payer: Aetna of CA HMO/PPO |
$50.87
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$71.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$46.07
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$46.07
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$40.56
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$49.49
|
| Rate for Payer: Blue Distinction Transplant |
$50.26
|
| Rate for Payer: Blue Shield of California Commercial |
$52.69
|
| Rate for Payer: Blue Shield of California EPN |
$40.96
|
| Rate for Payer: Cash Price |
$37.69
|
| Rate for Payer: Central Health Plan Commercial |
$67.01
|
| Rate for Payer: Cigna of CA HMO |
$58.63
|
| Rate for Payer: Cigna of CA PPO |
$58.63
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$71.20
|
| Rate for Payer: Dignity Health Media |
$71.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$71.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$33.50
|
| Rate for Payer: EPIC Health Plan Transplant |
$33.50
|
| Rate for Payer: Galaxy Health WC |
$71.20
|
| Rate for Payer: Global Benefits Group Commercial |
$50.26
|
| Rate for Payer: Health Management Network EPO/PPO |
$75.38
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$62.82
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$29.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$55.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$31.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$16.75
|
| Rate for Payer: Multiplan Commercial |
$62.82
|
| Rate for Payer: Networks By Design Commercial |
$54.44
|
| Rate for Payer: Prime Health Services Commercial |
$71.20
|
| Rate for Payer: Riverside University Health System MISP |
$33.50
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$50.26
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$50.26
|
| Rate for Payer: United Healthcare All Other Commercial |
$41.88
|
| Rate for Payer: United Healthcare All Other HMO |
$41.88
|
| Rate for Payer: United Healthcare HMO Rider |
$41.88
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$41.88
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$71.20
|
| Rate for Payer: Vantage Medical Group Senior |
$71.20
|
|
|
FOSFOMYCIN TROMETHAMINE 3 GRAM ORAL PACKET [14825]
|
Facility
|
IP
|
$96.38
|
|
|
Service Code
|
NDC 70700-268-99
|
| Hospital Charge Code |
ERX14825
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$19.28 |
| Max. Negotiated Rate |
$86.74 |
| Rate for Payer: Blue Shield of California Commercial |
$72.28
|
| Rate for Payer: Blue Shield of California EPN |
$51.47
|
| Rate for Payer: Cash Price |
$43.37
|
| Rate for Payer: Central Health Plan Commercial |
$77.10
|
| Rate for Payer: Cigna of CA HMO |
$67.47
|
| Rate for Payer: Cigna of CA PPO |
$67.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$38.55
|
| Rate for Payer: Galaxy Health WC |
$81.92
|
| Rate for Payer: Global Benefits Group Commercial |
$57.83
|
| Rate for Payer: Health Management Network EPO/PPO |
$86.74
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$64.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$36.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$19.28
|
| Rate for Payer: Multiplan Commercial |
$72.28
|
| Rate for Payer: Networks By Design Commercial |
$62.65
|
| Rate for Payer: Prime Health Services Commercial |
$81.92
|
|
|
FOSFOMYCIN TROMETHAMINE 3 GRAM ORAL PACKET [14825]
|
Facility
|
IP
|
$109.52
|
|
|
Service Code
|
NDC 0456-4300-01
|
| Hospital Charge Code |
ERX14825
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$21.90 |
| Max. Negotiated Rate |
$98.57 |
| Rate for Payer: Blue Shield of California Commercial |
$82.14
|
| Rate for Payer: Blue Shield of California EPN |
$58.48
|
| Rate for Payer: Cash Price |
$49.28
|
| Rate for Payer: Central Health Plan Commercial |
$87.62
|
| Rate for Payer: Cigna of CA HMO |
$76.66
|
| Rate for Payer: Cigna of CA PPO |
$76.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$43.81
|
| Rate for Payer: Galaxy Health WC |
$93.09
|
| Rate for Payer: Global Benefits Group Commercial |
$65.71
|
| Rate for Payer: Health Management Network EPO/PPO |
$98.57
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$73.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$41.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$21.90
|
| Rate for Payer: Multiplan Commercial |
$82.14
|
| Rate for Payer: Networks By Design Commercial |
$71.19
|
| Rate for Payer: Prime Health Services Commercial |
$93.09
|
|
|
FOSFOMYCIN TROMETHAMINE 3 GRAM ORAL PACKET [14825]
|
Facility
|
OP
|
$96.38
|
|
|
Service Code
|
NDC 70700-268-94
|
| Hospital Charge Code |
ERX14825
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$19.28 |
| Max. Negotiated Rate |
$86.74 |
| Rate for Payer: Aetna of CA HMO/PPO |
$58.53
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$81.92
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$53.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$53.01
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$46.67
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$56.94
|
| Rate for Payer: Blue Distinction Transplant |
$57.83
|
| Rate for Payer: Blue Shield of California Commercial |
$60.62
|
| Rate for Payer: Blue Shield of California EPN |
$47.13
|
| Rate for Payer: Cash Price |
$43.37
|
| Rate for Payer: Central Health Plan Commercial |
$77.10
|
| Rate for Payer: Cigna of CA HMO |
$67.47
|
| Rate for Payer: Cigna of CA PPO |
$67.47
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$81.92
|
| Rate for Payer: Dignity Health Media |
$81.92
|
| Rate for Payer: Dignity Health Medi-Cal |
$81.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$38.55
|
| Rate for Payer: EPIC Health Plan Transplant |
$38.55
|
| Rate for Payer: Galaxy Health WC |
$81.92
|
| Rate for Payer: Global Benefits Group Commercial |
$57.83
|
| Rate for Payer: Health Management Network EPO/PPO |
$86.74
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$72.28
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$33.73
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$64.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$36.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$19.28
|
| Rate for Payer: Multiplan Commercial |
$72.28
|
| Rate for Payer: Networks By Design Commercial |
$62.65
|
| Rate for Payer: Prime Health Services Commercial |
$81.92
|
| Rate for Payer: Riverside University Health System MISP |
$38.55
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$57.83
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$57.83
|
| Rate for Payer: United Healthcare All Other Commercial |
$48.19
|
| Rate for Payer: United Healthcare All Other HMO |
$48.19
|
| Rate for Payer: United Healthcare HMO Rider |
$48.19
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$48.19
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$81.92
|
| Rate for Payer: Vantage Medical Group Senior |
$81.92
|
|
|
FOSFOMYCIN TROMETHAMINE 3 GRAM ORAL PACKET [14825]
|
Facility
|
OP
|
$109.52
|
|
|
Service Code
|
NDC 0456-4300-01
|
| Hospital Charge Code |
ERX14825
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$21.90 |
| Max. Negotiated Rate |
$98.57 |
| Rate for Payer: Aetna of CA HMO/PPO |
$66.51
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$93.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$60.24
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$60.24
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$53.03
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$64.70
|
| Rate for Payer: Blue Distinction Transplant |
$65.71
|
| Rate for Payer: Blue Shield of California Commercial |
$68.89
|
| Rate for Payer: Blue Shield of California EPN |
$53.56
|
| Rate for Payer: Cash Price |
$49.28
|
| Rate for Payer: Central Health Plan Commercial |
$87.62
|
| Rate for Payer: Cigna of CA HMO |
$76.66
|
| Rate for Payer: Cigna of CA PPO |
$76.66
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$93.09
|
| Rate for Payer: Dignity Health Media |
$93.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$93.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$43.81
|
| Rate for Payer: EPIC Health Plan Transplant |
$43.81
|
| Rate for Payer: Galaxy Health WC |
$93.09
|
| Rate for Payer: Global Benefits Group Commercial |
$65.71
|
| Rate for Payer: Health Management Network EPO/PPO |
$98.57
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$82.14
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$38.33
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$73.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$41.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$21.90
|
| Rate for Payer: Multiplan Commercial |
$82.14
|
| Rate for Payer: Networks By Design Commercial |
$71.19
|
| Rate for Payer: Prime Health Services Commercial |
$93.09
|
| Rate for Payer: Riverside University Health System MISP |
$43.81
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$65.71
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$65.71
|
| Rate for Payer: United Healthcare All Other Commercial |
$54.76
|
| Rate for Payer: United Healthcare All Other HMO |
$54.76
|
| Rate for Payer: United Healthcare HMO Rider |
$54.76
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$54.76
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$93.09
|
| Rate for Payer: Vantage Medical Group Senior |
$93.09
|
|
|
FOSFOMYCIN TROMETHAMINE 3 GRAM ORAL PACKET [14825]
|
Facility
|
IP
|
$83.76
|
|
|
Service Code
|
NDC 67877-749-57
|
| Hospital Charge Code |
ERX14825
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$16.75 |
| Max. Negotiated Rate |
$75.38 |
| Rate for Payer: Blue Shield of California Commercial |
$62.82
|
| Rate for Payer: Blue Shield of California EPN |
$44.73
|
| Rate for Payer: Cash Price |
$37.69
|
| Rate for Payer: Central Health Plan Commercial |
$67.01
|
| Rate for Payer: Cigna of CA HMO |
$58.63
|
| Rate for Payer: Cigna of CA PPO |
$58.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$33.50
|
| Rate for Payer: Galaxy Health WC |
$71.20
|
| Rate for Payer: Global Benefits Group Commercial |
$50.26
|
| Rate for Payer: Health Management Network EPO/PPO |
$75.38
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$55.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$31.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$16.75
|
| Rate for Payer: Multiplan Commercial |
$62.82
|
| Rate for Payer: Networks By Design Commercial |
$54.44
|
| Rate for Payer: Prime Health Services Commercial |
$71.20
|
|
|
FOSFOMYCIN TROMETHAMINE 3 GRAM ORAL PACKET [14825]
|
Facility
|
IP
|
$96.38
|
|
|
Service Code
|
NDC 70700-268-94
|
| Hospital Charge Code |
ERX14825
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$19.28 |
| Max. Negotiated Rate |
$86.74 |
| Rate for Payer: Blue Shield of California Commercial |
$72.28
|
| Rate for Payer: Blue Shield of California EPN |
$51.47
|
| Rate for Payer: Cash Price |
$43.37
|
| Rate for Payer: Central Health Plan Commercial |
$77.10
|
| Rate for Payer: Cigna of CA HMO |
$67.47
|
| Rate for Payer: Cigna of CA PPO |
$67.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$38.55
|
| Rate for Payer: Galaxy Health WC |
$81.92
|
| Rate for Payer: Global Benefits Group Commercial |
$57.83
|
| Rate for Payer: Health Management Network EPO/PPO |
$86.74
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$64.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$36.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$19.28
|
| Rate for Payer: Multiplan Commercial |
$72.28
|
| Rate for Payer: Networks By Design Commercial |
$62.65
|
| Rate for Payer: Prime Health Services Commercial |
$81.92
|
|
|
FOSFOMYCIN TROMETHAMINE 3 GRAM ORAL PACKET [14825]
|
Facility
|
IP
|
$109.52
|
|
|
Service Code
|
NDC 0456-4300-08
|
| Hospital Charge Code |
ERX14825
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$21.90 |
| Max. Negotiated Rate |
$98.57 |
| Rate for Payer: Blue Shield of California Commercial |
$82.14
|
| Rate for Payer: Blue Shield of California EPN |
$58.48
|
| Rate for Payer: Cash Price |
$49.28
|
| Rate for Payer: Central Health Plan Commercial |
$87.62
|
| Rate for Payer: Cigna of CA HMO |
$76.66
|
| Rate for Payer: Cigna of CA PPO |
$76.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$43.81
|
| Rate for Payer: Galaxy Health WC |
$93.09
|
| Rate for Payer: Global Benefits Group Commercial |
$65.71
|
| Rate for Payer: Health Management Network EPO/PPO |
$98.57
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$73.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$41.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$21.90
|
| Rate for Payer: Multiplan Commercial |
$82.14
|
| Rate for Payer: Networks By Design Commercial |
$71.19
|
| Rate for Payer: Prime Health Services Commercial |
$93.09
|
|
|
FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION [88011]
|
Facility
|
OP
|
$23.10
|
|
|
Service Code
|
CPT Q2009
|
| Hospital Charge Code |
1720991
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.62 |
| Max. Negotiated Rate |
$20.79 |
| Rate for Payer: Adventist Health Medi-Cal |
$4.80
|
| Rate for Payer: Adventist Health Medi-Cal |
$4.80
|
| Rate for Payer: Adventist Health Medi-Cal |
$4.80
|
| Rate for Payer: Aetna of CA HMO/PPO |
$19.08
|
| Rate for Payer: Aetna of CA HMO/PPO |
$19.08
|
| Rate for Payer: Aetna of CA HMO/PPO |
$19.08
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5.28
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5.28
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5.28
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.28
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.28
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.28
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$17.19
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$17.19
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$17.19
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$18.82
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$18.82
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$18.82
|
| Rate for Payer: Blue Distinction Transplant |
$13.86
|
| Rate for Payer: Blue Distinction Transplant |
$1.73
|
| Rate for Payer: Blue Distinction Transplant |
$5.40
|
| Rate for Payer: Blue Shield of California Commercial |
$6.13
|
| Rate for Payer: Blue Shield of California Commercial |
$6.13
|
| Rate for Payer: Blue Shield of California Commercial |
$6.13
|
| Rate for Payer: Blue Shield of California EPN |
$5.57
|
| Rate for Payer: Blue Shield of California EPN |
$5.57
|
| Rate for Payer: Blue Shield of California EPN |
$5.57
|
| Rate for Payer: Caremore Medicare Advantage |
$4.80
|
| Rate for Payer: Caremore Medicare Advantage |
$4.80
|
| Rate for Payer: Caremore Medicare Advantage |
$4.80
|
| Rate for Payer: Cash Price |
$10.40
|
| Rate for Payer: Cash Price |
$4.05
|
| Rate for Payer: Cash Price |
$1.30
|
| Rate for Payer: Cash Price |
$1.30
|
| Rate for Payer: Cash Price |
$4.05
|
| Rate for Payer: Cash Price |
$10.40
|
| Rate for Payer: Central Health Plan Commercial |
$2.30
|
| Rate for Payer: Central Health Plan Commercial |
$18.48
|
| Rate for Payer: Central Health Plan Commercial |
$7.20
|
| Rate for Payer: Cigna of CA HMO |
$16.17
|
| Rate for Payer: Cigna of CA HMO |
$2.02
|
| Rate for Payer: Cigna of CA HMO |
$6.30
|
| Rate for Payer: Cigna of CA PPO |
$2.02
|
| Rate for Payer: Cigna of CA PPO |
$6.30
|
| Rate for Payer: Cigna of CA PPO |
$16.17
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.20
|
| Rate for Payer: Dignity Health Media |
$4.80
|
| Rate for Payer: Dignity Health Media |
$4.80
|
| Rate for Payer: Dignity Health Media |
$4.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.28
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.28
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.48
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$4.80
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$4.80
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$4.80
|
| Rate for Payer: EPIC Health Plan Transplant |
$4.80
|
| Rate for Payer: EPIC Health Plan Transplant |
$4.80
|
| Rate for Payer: EPIC Health Plan Transplant |
$4.80
|
| Rate for Payer: Galaxy Health WC |
$19.64
|
| Rate for Payer: Galaxy Health WC |
$7.65
|
| Rate for Payer: Galaxy Health WC |
$2.45
|
| Rate for Payer: Global Benefits Group Commercial |
$1.73
|
| Rate for Payer: Global Benefits Group Commercial |
$5.40
|
| Rate for Payer: Global Benefits Group Commercial |
$13.86
|
| Rate for Payer: Health Management Network EPO/PPO |
$8.10
|
| Rate for Payer: Health Management Network EPO/PPO |
$20.79
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.59
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$2.16
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$17.32
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$6.75
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$7.87
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$7.87
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$7.87
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$7.92
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$7.92
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$7.92
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4.80
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4.80
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4.80
|
| Rate for Payer: InnovAge PACE Commercial |
$7.20
|
| Rate for Payer: InnovAge PACE Commercial |
$7.20
|
| Rate for Payer: InnovAge PACE Commercial |
$7.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$15.41
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.92
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$6.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.80
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4.80
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4.80
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.62
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$6.43
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$6.43
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$6.43
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$6.43
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$6.43
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$6.43
|
| Rate for Payer: Multiplan Commercial |
$17.32
|
| Rate for Payer: Multiplan Commercial |
$2.16
|
| Rate for Payer: Multiplan Commercial |
$6.75
|
| Rate for Payer: Networks By Design Commercial |
$11.55
|
| Rate for Payer: Networks By Design Commercial |
$1.44
|
| Rate for Payer: Networks By Design Commercial |
$4.50
|
| Rate for Payer: Prime Health Services Commercial |
$2.45
|
| Rate for Payer: Prime Health Services Commercial |
$19.64
|
| Rate for Payer: Prime Health Services Commercial |
$7.65
|
| Rate for Payer: Prime Health Services Medicare |
$5.09
|
| Rate for Payer: Prime Health Services Medicare |
$5.09
|
| Rate for Payer: Prime Health Services Medicare |
$5.09
|
| Rate for Payer: Riverside University Health System MISP |
$5.28
|
| Rate for Payer: Riverside University Health System MISP |
$5.28
|
| Rate for Payer: Riverside University Health System MISP |
$5.28
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$13.86
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$5.40
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.73
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$13.86
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.73
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$5.40
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.44
|
| Rate for Payer: United Healthcare All Other Commercial |
$4.50
|
| Rate for Payer: United Healthcare All Other Commercial |
$11.55
|
| Rate for Payer: United Healthcare All Other HMO |
$4.50
|
| Rate for Payer: United Healthcare All Other HMO |
$1.44
|
| Rate for Payer: United Healthcare All Other HMO |
$11.55
|
| Rate for Payer: United Healthcare HMO Rider |
$4.50
|
| Rate for Payer: United Healthcare HMO Rider |
$11.55
|
| Rate for Payer: United Healthcare HMO Rider |
$1.44
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.44
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4.50
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$11.55
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7.20
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7.20
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.28
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.28
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.28
|
| Rate for Payer: Vantage Medical Group Senior |
$4.80
|
| Rate for Payer: Vantage Medical Group Senior |
$4.80
|
| Rate for Payer: Vantage Medical Group Senior |
$4.80
|
|
|
FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION [88011]
|
Facility
|
IP
|
$9.00
|
|
|
Service Code
|
CPT Q2009
|
| Hospital Charge Code |
1720991
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.80 |
| Max. Negotiated Rate |
$8.10 |
| Rate for Payer: Blue Shield of California Commercial |
$6.75
|
| Rate for Payer: Blue Shield of California Commercial |
$2.16
|
| Rate for Payer: Blue Shield of California Commercial |
$17.32
|
| Rate for Payer: Blue Shield of California EPN |
$12.34
|
| Rate for Payer: Blue Shield of California EPN |
$1.54
|
| Rate for Payer: Blue Shield of California EPN |
$4.81
|
| Rate for Payer: Cash Price |
$1.30
|
| Rate for Payer: Cash Price |
$4.05
|
| Rate for Payer: Cash Price |
$10.40
|
| Rate for Payer: Central Health Plan Commercial |
$7.20
|
| Rate for Payer: Central Health Plan Commercial |
$2.30
|
| Rate for Payer: Central Health Plan Commercial |
$18.48
|
| Rate for Payer: Cigna of CA HMO |
$2.02
|
| Rate for Payer: Cigna of CA HMO |
$6.30
|
| Rate for Payer: Cigna of CA HMO |
$16.17
|
| Rate for Payer: Cigna of CA PPO |
$16.17
|
| Rate for Payer: Cigna of CA PPO |
$6.30
|
| Rate for Payer: Cigna of CA PPO |
$2.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.15
|
| Rate for Payer: EPIC Health Plan Transplant |
$3.60
|
| Rate for Payer: EPIC Health Plan Transplant |
$9.24
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.15
|
| Rate for Payer: Galaxy Health WC |
$2.45
|
| Rate for Payer: Galaxy Health WC |
$7.65
|
| Rate for Payer: Galaxy Health WC |
$19.64
|
| Rate for Payer: Global Benefits Group Commercial |
$5.40
|
| Rate for Payer: Global Benefits Group Commercial |
$13.86
|
| Rate for Payer: Global Benefits Group Commercial |
$1.73
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.59
|
| Rate for Payer: Health Management Network EPO/PPO |
$8.10
|
| Rate for Payer: Health Management Network EPO/PPO |
$20.79
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$15.41
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.92
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$6.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.62
|
| Rate for Payer: Multiplan Commercial |
$6.75
|
| Rate for Payer: Multiplan Commercial |
$17.32
|
| Rate for Payer: Multiplan Commercial |
$2.16
|
| Rate for Payer: Networks By Design Commercial |
$1.44
|
| Rate for Payer: Networks By Design Commercial |
$4.50
|
| Rate for Payer: Networks By Design Commercial |
$11.55
|
| Rate for Payer: Prime Health Services Commercial |
$7.65
|
| Rate for Payer: Prime Health Services Commercial |
$2.45
|
| Rate for Payer: Prime Health Services Commercial |
$19.64
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.40
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.09
|
| Rate for Payer: United Healthcare All Other Commercial |
$8.72
|
| Rate for Payer: United Healthcare All Other HMO |
$3.32
|
| Rate for Payer: United Healthcare All Other HMO |
$8.52
|
| Rate for Payer: United Healthcare All Other HMO |
$1.06
|
| Rate for Payer: United Healthcare HMO Rider |
$3.25
|
| Rate for Payer: United Healthcare HMO Rider |
$1.04
|
| Rate for Payer: United Healthcare HMO Rider |
$8.33
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.95
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$7.62
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.97
|
|
|
FOSPHENYTOIN 500 MG PE/10 ML INJECTION SOLUTION [88010]
|
Facility
|
OP
|
$13.86
|
|
|
Service Code
|
CPT Q2009
|
| Hospital Charge Code |
1720986
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.77 |
| Max. Negotiated Rate |
$19.08 |
| Rate for Payer: Adventist Health Medi-Cal |
$4.80
|
| Rate for Payer: Aetna of CA HMO/PPO |
$19.08
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5.28
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.28
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$17.19
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$18.82
|
| Rate for Payer: Blue Distinction Transplant |
$8.32
|
| Rate for Payer: Blue Shield of California Commercial |
$6.13
|
| Rate for Payer: Blue Shield of California EPN |
$5.57
|
| Rate for Payer: Caremore Medicare Advantage |
$4.80
|
| Rate for Payer: Cash Price |
$6.24
|
| Rate for Payer: Cash Price |
$6.24
|
| Rate for Payer: Central Health Plan Commercial |
$11.09
|
| Rate for Payer: Cigna of CA HMO |
$9.70
|
| Rate for Payer: Cigna of CA PPO |
$9.70
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.20
|
| Rate for Payer: Dignity Health Media |
$4.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.48
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$4.80
|
| Rate for Payer: EPIC Health Plan Transplant |
$4.80
|
| Rate for Payer: Galaxy Health WC |
$11.78
|
| Rate for Payer: Global Benefits Group Commercial |
$8.32
|
| Rate for Payer: Health Management Network EPO/PPO |
$12.47
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$10.40
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$7.87
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$7.92
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4.80
|
| Rate for Payer: InnovAge PACE Commercial |
$7.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$9.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.28
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.77
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$6.43
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$6.43
|
| Rate for Payer: Multiplan Commercial |
$10.40
|
| Rate for Payer: Networks By Design Commercial |
$6.93
|
| Rate for Payer: Prime Health Services Commercial |
$11.78
|
| Rate for Payer: Prime Health Services Medicare |
$5.09
|
| Rate for Payer: Riverside University Health System MISP |
$5.28
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$8.32
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$8.32
|
| Rate for Payer: United Healthcare All Other Commercial |
$6.93
|
| Rate for Payer: United Healthcare All Other HMO |
$6.93
|
| Rate for Payer: United Healthcare HMO Rider |
$6.93
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6.93
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.28
|
| Rate for Payer: Vantage Medical Group Senior |
$4.80
|
|
|
FOSPHENYTOIN 500 MG PE/10 ML INJECTION SOLUTION [88010]
|
Facility
|
IP
|
$13.86
|
|
|
Service Code
|
CPT Q2009
|
| Hospital Charge Code |
1720986
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.77 |
| Max. Negotiated Rate |
$12.47 |
| Rate for Payer: Blue Shield of California Commercial |
$10.40
|
| Rate for Payer: Blue Shield of California EPN |
$7.40
|
| Rate for Payer: Cash Price |
$6.24
|
| Rate for Payer: Central Health Plan Commercial |
$11.09
|
| Rate for Payer: Cigna of CA HMO |
$9.70
|
| Rate for Payer: Cigna of CA PPO |
$9.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.54
|
| Rate for Payer: EPIC Health Plan Transplant |
$5.54
|
| Rate for Payer: Galaxy Health WC |
$11.78
|
| Rate for Payer: Global Benefits Group Commercial |
$8.32
|
| Rate for Payer: Health Management Network EPO/PPO |
$12.47
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$9.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.77
|
| Rate for Payer: Multiplan Commercial |
$10.40
|
| Rate for Payer: Networks By Design Commercial |
$6.93
|
| Rate for Payer: Prime Health Services Commercial |
$11.78
|
| Rate for Payer: United Healthcare All Other Commercial |
$5.23
|
| Rate for Payer: United Healthcare All Other HMO |
$5.11
|
| Rate for Payer: United Healthcare HMO Rider |
$5.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4.57
|
|
|
FOSPHENYTOIN 50 MG PE/ML IV INJECTION SOLUTION WRAP [408056880]
|
Facility
|
OP
|
$9.00
|
|
|
Service Code
|
CPT Q2009
|
| Hospital Charge Code |
1720991
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.80 |
| Max. Negotiated Rate |
$19.08 |
| Rate for Payer: Adventist Health Medi-Cal |
$4.80
|
| Rate for Payer: Adventist Health Medi-Cal |
$4.80
|
| Rate for Payer: Adventist Health Medi-Cal |
$4.80
|
| Rate for Payer: Aetna of CA HMO/PPO |
$19.08
|
| Rate for Payer: Aetna of CA HMO/PPO |
$19.08
|
| Rate for Payer: Aetna of CA HMO/PPO |
$19.08
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5.28
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5.28
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5.28
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.28
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.28
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.28
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$17.19
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$17.19
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$17.19
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$18.82
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$18.82
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$18.82
|
| Rate for Payer: Blue Distinction Transplant |
$1.73
|
| Rate for Payer: Blue Distinction Transplant |
$5.40
|
| Rate for Payer: Blue Distinction Transplant |
$13.86
|
| Rate for Payer: Blue Shield of California Commercial |
$6.13
|
| Rate for Payer: Blue Shield of California Commercial |
$6.13
|
| Rate for Payer: Blue Shield of California Commercial |
$6.13
|
| Rate for Payer: Blue Shield of California EPN |
$5.57
|
| Rate for Payer: Blue Shield of California EPN |
$5.57
|
| Rate for Payer: Blue Shield of California EPN |
$5.57
|
| Rate for Payer: Caremore Medicare Advantage |
$4.80
|
| Rate for Payer: Caremore Medicare Advantage |
$4.80
|
| Rate for Payer: Caremore Medicare Advantage |
$4.80
|
| Rate for Payer: Cash Price |
$10.40
|
| Rate for Payer: Cash Price |
$4.05
|
| Rate for Payer: Cash Price |
$1.30
|
| Rate for Payer: Cash Price |
$1.30
|
| Rate for Payer: Cash Price |
$4.05
|
| Rate for Payer: Cash Price |
$10.40
|
| Rate for Payer: Central Health Plan Commercial |
$7.20
|
| Rate for Payer: Central Health Plan Commercial |
$2.30
|
| Rate for Payer: Central Health Plan Commercial |
$18.48
|
| Rate for Payer: Cigna of CA HMO |
$6.30
|
| Rate for Payer: Cigna of CA HMO |
$2.02
|
| Rate for Payer: Cigna of CA HMO |
$16.17
|
| Rate for Payer: Cigna of CA PPO |
$6.30
|
| Rate for Payer: Cigna of CA PPO |
$16.17
|
| Rate for Payer: Cigna of CA PPO |
$2.02
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.20
|
| Rate for Payer: Dignity Health Media |
$4.80
|
| Rate for Payer: Dignity Health Media |
$4.80
|
| Rate for Payer: Dignity Health Media |
$4.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.28
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.28
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.48
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$4.80
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$4.80
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$4.80
|
| Rate for Payer: EPIC Health Plan Transplant |
$4.80
|
| Rate for Payer: EPIC Health Plan Transplant |
$4.80
|
| Rate for Payer: EPIC Health Plan Transplant |
$4.80
|
| Rate for Payer: Galaxy Health WC |
$7.65
|
| Rate for Payer: Galaxy Health WC |
$19.64
|
| Rate for Payer: Galaxy Health WC |
$2.45
|
| Rate for Payer: Global Benefits Group Commercial |
$13.86
|
| Rate for Payer: Global Benefits Group Commercial |
$5.40
|
| Rate for Payer: Global Benefits Group Commercial |
$1.73
|
| Rate for Payer: Health Management Network EPO/PPO |
$8.10
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.59
|
| Rate for Payer: Health Management Network EPO/PPO |
$20.79
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$2.16
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$17.32
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$6.75
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$7.87
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$7.87
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$7.87
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$7.92
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$7.92
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$7.92
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4.80
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4.80
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4.80
|
| Rate for Payer: InnovAge PACE Commercial |
$7.20
|
| Rate for Payer: InnovAge PACE Commercial |
$7.20
|
| Rate for Payer: InnovAge PACE Commercial |
$7.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.92
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$6.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$15.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.43
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4.80
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4.80
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.58
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$6.43
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$6.43
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$6.43
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$6.43
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$6.43
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$6.43
|
| Rate for Payer: Multiplan Commercial |
$2.16
|
| Rate for Payer: Multiplan Commercial |
$6.75
|
| Rate for Payer: Multiplan Commercial |
$17.32
|
| Rate for Payer: Networks By Design Commercial |
$1.44
|
| Rate for Payer: Networks By Design Commercial |
$4.50
|
| Rate for Payer: Networks By Design Commercial |
$11.55
|
| Rate for Payer: Prime Health Services Commercial |
$2.45
|
| Rate for Payer: Prime Health Services Commercial |
$19.64
|
| Rate for Payer: Prime Health Services Commercial |
$7.65
|
| Rate for Payer: Prime Health Services Medicare |
$5.09
|
| Rate for Payer: Prime Health Services Medicare |
$5.09
|
| Rate for Payer: Prime Health Services Medicare |
$5.09
|
| Rate for Payer: Riverside University Health System MISP |
$5.28
|
| Rate for Payer: Riverside University Health System MISP |
$5.28
|
| Rate for Payer: Riverside University Health System MISP |
$5.28
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.73
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$13.86
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$5.40
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$13.86
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$5.40
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.73
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.44
|
| Rate for Payer: United Healthcare All Other Commercial |
$11.55
|
| Rate for Payer: United Healthcare All Other Commercial |
$4.50
|
| Rate for Payer: United Healthcare All Other HMO |
$11.55
|
| Rate for Payer: United Healthcare All Other HMO |
$1.44
|
| Rate for Payer: United Healthcare All Other HMO |
$4.50
|
| Rate for Payer: United Healthcare HMO Rider |
$11.55
|
| Rate for Payer: United Healthcare HMO Rider |
$4.50
|
| Rate for Payer: United Healthcare HMO Rider |
$1.44
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4.50
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$11.55
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.44
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7.20
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7.20
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.28
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.28
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.28
|
| Rate for Payer: Vantage Medical Group Senior |
$4.80
|
| Rate for Payer: Vantage Medical Group Senior |
$4.80
|
| Rate for Payer: Vantage Medical Group Senior |
$4.80
|
|
|
FOSPHENYTOIN 50 MG PE/ML IV INJECTION SOLUTION WRAP [408056880]
|
Facility
|
IP
|
$13.86
|
|
|
Service Code
|
CPT Q2009
|
| Hospital Charge Code |
1720986
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.77 |
| Max. Negotiated Rate |
$12.47 |
| Rate for Payer: Blue Shield of California Commercial |
$10.40
|
| Rate for Payer: Blue Shield of California EPN |
$7.40
|
| Rate for Payer: Cash Price |
$6.24
|
| Rate for Payer: Central Health Plan Commercial |
$11.09
|
| Rate for Payer: Cigna of CA HMO |
$9.70
|
| Rate for Payer: Cigna of CA PPO |
$9.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.54
|
| Rate for Payer: EPIC Health Plan Transplant |
$5.54
|
| Rate for Payer: Galaxy Health WC |
$11.78
|
| Rate for Payer: Global Benefits Group Commercial |
$8.32
|
| Rate for Payer: Health Management Network EPO/PPO |
$12.47
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$9.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.77
|
| Rate for Payer: Multiplan Commercial |
$10.40
|
| Rate for Payer: Networks By Design Commercial |
$6.93
|
| Rate for Payer: Prime Health Services Commercial |
$11.78
|
| Rate for Payer: United Healthcare All Other Commercial |
$5.23
|
| Rate for Payer: United Healthcare All Other HMO |
$5.11
|
| Rate for Payer: United Healthcare HMO Rider |
$5.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4.57
|
|
