|
POLYETHYLENE GLYCOL 400 1 % EYE DROPS [232731]
|
Facility
OP
|
$0.42
|
|
|
Service Code
|
NDC 7430001067
|
| Hospital Charge Code |
NDG232731
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.36 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.22
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.29
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.36
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.23
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.32
|
| Rate for Payer: Blue Shield of California Commercial |
$0.26
|
| Rate for Payer: Blue Shield of California EPN |
$0.25
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.27
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.36
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.36
|
| Rate for Payer: Dignity Health Senior |
$0.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.27
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.26
|
| Rate for Payer: Heritage Provider Network Senior |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.32
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.36
|
| Rate for Payer: Vantage Medical Group Senior |
$0.36
|
|
|
POLYMYXIN B SULFATE 10,000 UNIT-TRIMETHOPRIM 1 MG/ML EYE DROPS [111465]
|
Facility
OP
|
$9.58
|
|
|
Service Code
|
NDC 0023-7824-10
|
| Hospital Charge Code |
1740272
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.73 |
| Max. Negotiated Rate |
$8.14 |
| Rate for Payer: Adventist Health Commercial |
$1.92
|
| Rate for Payer: Aetna of CA Gatekeeper |
$5.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.58
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$8.14
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$5.27
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$7.18
|
| Rate for Payer: Blue Shield of California Commercial |
$5.95
|
| Rate for Payer: Blue Shield of California EPN |
$5.62
|
| Rate for Payer: Cash Price |
$4.31
|
| Rate for Payer: Cigna of CA HMO/PPO |
$6.23
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$8.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$8.14
|
| Rate for Payer: Dignity Health Senior |
$8.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.93
|
| Rate for Payer: Heritage Provider Network Senior |
$5.93
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.40
|
| Rate for Payer: Multiplan Commercial |
$7.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8.14
|
| Rate for Payer: Vantage Medical Group Senior |
$8.14
|
|
|
POLYMYXIN B SULFATE 10,000 UNIT-TRIMETHOPRIM 1 MG/ML EYE DROPS [111465]
|
Facility
IP
|
$1.24
|
|
|
Service Code
|
NDC 61314-628-10
|
| Hospital Charge Code |
1740272
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Adventist Health Commercial |
$0.25
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.85
|
| Rate for Payer: Cash Price |
$0.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.67
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.84
|
| Rate for Payer: Heritage Provider Network Senior |
$0.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.31
|
| Rate for Payer: Multiplan Commercial |
$0.93
|
|
|
POLYMYXIN B SULFATE 10,000 UNIT-TRIMETHOPRIM 1 MG/ML EYE DROPS [111465]
|
Facility
OP
|
$1.31
|
|
|
Service Code
|
NDC 60758-908-10
|
| Hospital Charge Code |
1740272
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$1.11 |
| Rate for Payer: Adventist Health Commercial |
$0.26
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.70
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.90
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.11
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.72
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.98
|
| Rate for Payer: Blue Shield of California Commercial |
$0.81
|
| Rate for Payer: Blue Shield of California EPN |
$0.77
|
| Rate for Payer: Cash Price |
$0.59
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.85
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.11
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.11
|
| Rate for Payer: Dignity Health Senior |
$1.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.84
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.81
|
| Rate for Payer: Heritage Provider Network Senior |
$0.81
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.33
|
| Rate for Payer: Multiplan Commercial |
$0.98
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.11
|
| Rate for Payer: Vantage Medical Group Senior |
$1.11
|
|
|
POLYMYXIN B SULFATE 10,000 UNIT-TRIMETHOPRIM 1 MG/ML EYE DROPS [111465]
|
Facility
OP
|
$1.24
|
|
|
Service Code
|
NDC 61314-628-10
|
| Hospital Charge Code |
1740272
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$1.05 |
| Rate for Payer: Adventist Health Commercial |
$0.25
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.66
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.85
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.05
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.68
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.93
|
| Rate for Payer: Blue Shield of California Commercial |
$0.77
|
| Rate for Payer: Blue Shield of California EPN |
$0.73
|
| Rate for Payer: Cash Price |
$0.56
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.81
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.05
|
| Rate for Payer: Dignity Health Senior |
$1.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.79
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.77
|
| Rate for Payer: Heritage Provider Network Senior |
$0.77
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.31
|
| Rate for Payer: Multiplan Commercial |
$0.93
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.05
|
| Rate for Payer: Vantage Medical Group Senior |
$1.05
|
|
|
POLYMYXIN B SULFATE 10,000 UNIT-TRIMETHOPRIM 1 MG/ML EYE DROPS [111465]
|
Facility
IP
|
$1.31
|
|
|
Service Code
|
NDC 60758-908-10
|
| Hospital Charge Code |
1740272
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$0.98 |
| Rate for Payer: Adventist Health Commercial |
$0.26
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.90
|
| Rate for Payer: Cash Price |
$0.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.71
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.89
|
| Rate for Payer: Heritage Provider Network Senior |
$0.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.33
|
| Rate for Payer: Multiplan Commercial |
$0.98
|
|
|
POLYMYXIN B SULFATE 10,000 UNIT-TRIMETHOPRIM 1 MG/ML EYE DROPS [111465]
|
Facility
IP
|
$9.58
|
|
|
Service Code
|
NDC 0023-7824-10
|
| Hospital Charge Code |
1740272
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.73 |
| Max. Negotiated Rate |
$7.18 |
| Rate for Payer: Adventist Health Commercial |
$1.92
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.58
|
| Rate for Payer: Cash Price |
$4.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.17
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.49
|
| Rate for Payer: Heritage Provider Network Senior |
$6.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.40
|
| Rate for Payer: Multiplan Commercial |
$7.18
|
|
|
POLYMYXIN B SULFATE 500,000 UNIT SOLUTION FOR INJECTION [6393]
|
Facility
OP
|
$12.00
|
|
|
Service Code
|
NDC 55150-234-10
|
| Hospital Charge Code |
1756008
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.17 |
| Max. Negotiated Rate |
$10.20 |
| Rate for Payer: Adventist Health Commercial |
$2.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6.41
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8.24
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$10.20
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$6.60
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$9.00
|
| Rate for Payer: Blue Shield of California Commercial |
$7.45
|
| Rate for Payer: Blue Shield of California EPN |
$7.04
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$10.20
|
| Rate for Payer: Dignity Health Senior |
$10.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.68
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.43
|
| Rate for Payer: Heritage Provider Network Senior |
$7.43
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.00
|
| Rate for Payer: Multiplan Commercial |
$9.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$10.20
|
| Rate for Payer: Vantage Medical Group Senior |
$10.20
|
|
|
POLYMYXIN B SULFATE 500,000 UNIT SOLUTION FOR INJECTION [6393]
|
Facility
IP
|
$12.00
|
|
|
Service Code
|
NDC 55150-234-10
|
| Hospital Charge Code |
1756008
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.17 |
| Max. Negotiated Rate |
$9.00 |
| Rate for Payer: Adventist Health Commercial |
$2.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8.24
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.48
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.12
|
| Rate for Payer: Heritage Provider Network Senior |
$8.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.00
|
| Rate for Payer: Multiplan Commercial |
$9.00
|
|
|
POLYOXYL (100) STEARYL ETHER (BULK) 100 % WAX [192296]
|
Facility
OP
|
$1.73
|
|
|
Service Code
|
NDC 5192723020
|
| Hospital Charge Code |
NDG192296
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$1.47 |
| Rate for Payer: Adventist Health Commercial |
$0.35
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.92
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.19
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.47
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.95
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.30
|
| Rate for Payer: Blue Shield of California Commercial |
$1.07
|
| Rate for Payer: Blue Shield of California EPN |
$1.02
|
| Rate for Payer: Cash Price |
$0.78
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.47
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.47
|
| Rate for Payer: Dignity Health Senior |
$1.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.11
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.07
|
| Rate for Payer: Heritage Provider Network Senior |
$1.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.83
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.43
|
| Rate for Payer: Multiplan Commercial |
$1.30
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.47
|
| Rate for Payer: Vantage Medical Group Senior |
$1.47
|
|
|
POLYOXYL (100) STEARYL ETHER (BULK) 100 % WAX [192296]
|
Facility
IP
|
$1.73
|
|
|
Service Code
|
NDC 5192723020
|
| Hospital Charge Code |
NDG192296
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$1.30 |
| Rate for Payer: Adventist Health Commercial |
$0.35
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.19
|
| Rate for Payer: Cash Price |
$0.78
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.93
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.17
|
| Rate for Payer: Heritage Provider Network Senior |
$1.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.43
|
| Rate for Payer: Multiplan Commercial |
$1.30
|
|
|
POLYVINYL ALCOHOL 1.4 % EYE DROPS [27994]
|
Facility
OP
|
$0.47
|
|
|
Service Code
|
NDC 17478-060-12
|
| Hospital Charge Code |
1740338
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.40 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.25
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.32
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.40
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.26
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.35
|
| Rate for Payer: Blue Shield of California Commercial |
$0.29
|
| Rate for Payer: Blue Shield of California EPN |
$0.28
|
| Rate for Payer: Cash Price |
$0.21
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.31
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.40
|
| Rate for Payer: Dignity Health Senior |
$0.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.29
|
| Rate for Payer: Heritage Provider Network Senior |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.40
|
| Rate for Payer: Vantage Medical Group Senior |
$0.40
|
|
|
POLYVINYL ALCOHOL 1.4 % EYE DROPS [27994]
|
Facility
IP
|
$0.47
|
|
|
Service Code
|
NDC 17478-060-12
|
| Hospital Charge Code |
1740338
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.35 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.32
|
| Rate for Payer: Cash Price |
$0.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.32
|
| Rate for Payer: Heritage Provider Network Senior |
$0.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.35
|
|
|
PORACTANT ALFA 120 MG/1.5 ML INTRATRACHEAL SUSPENSION [27047]
|
Facility
OP
|
$435.45
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
1720928
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$78.82 |
| Max. Negotiated Rate |
$370.13 |
| Rate for Payer: Adventist Health Commercial |
$87.09
|
| Rate for Payer: Aetna of CA Gatekeeper |
$232.75
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$299.15
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$370.13
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$239.50
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$326.59
|
| Rate for Payer: Blue Shield of California Commercial |
$270.41
|
| Rate for Payer: Blue Shield of California EPN |
$255.61
|
| Rate for Payer: Cash Price |
$195.95
|
| Rate for Payer: Cigna of CA HMO/PPO |
$200.31
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$370.13
|
| Rate for Payer: Dignity Health Medi-Cal |
$370.13
|
| Rate for Payer: Dignity Health Senior |
$370.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$278.69
|
| Rate for Payer: Heritage Provider Network Commercial |
$201.61
|
| Rate for Payer: Heritage Provider Network Senior |
$201.61
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$209.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$78.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$108.86
|
| Rate for Payer: Multiplan Commercial |
$326.59
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$158.77
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$145.48
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$370.13
|
| Rate for Payer: Vantage Medical Group Senior |
$370.13
|
|
|
PORACTANT ALFA 120 MG/1.5 ML INTRATRACHEAL SUSPENSION [27047]
|
Facility
IP
|
$435.45
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
1720928
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$78.82 |
| Max. Negotiated Rate |
$326.59 |
| Rate for Payer: Adventist Health Commercial |
$87.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$299.15
|
| Rate for Payer: Cash Price |
$195.95
|
| Rate for Payer: Cigna of CA HMO/PPO |
$200.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$235.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$294.80
|
| Rate for Payer: Heritage Provider Network Senior |
$294.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$78.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$108.86
|
| Rate for Payer: Multiplan Commercial |
$326.59
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$158.77
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$145.48
|
|
|
PORACTANT ALFA 240 MG/3 ML INTRATRACHEAL SUSPENSION [117872]
|
Facility
OP
|
$429.33
|
|
|
Service Code
|
NDC 10122-510-03
|
| Hospital Charge Code |
1720929
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$77.71 |
| Max. Negotiated Rate |
$364.93 |
| Rate for Payer: Adventist Health Commercial |
$85.87
|
| Rate for Payer: Aetna of CA Gatekeeper |
$229.48
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$294.95
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$364.93
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$236.13
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$322.00
|
| Rate for Payer: Blue Shield of California Commercial |
$266.61
|
| Rate for Payer: Blue Shield of California EPN |
$252.02
|
| Rate for Payer: Cash Price |
$193.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$279.06
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$364.93
|
| Rate for Payer: Dignity Health Medi-Cal |
$364.93
|
| Rate for Payer: Dignity Health Senior |
$364.93
|
| Rate for Payer: EPIC Health Plan Commercial |
$274.77
|
| Rate for Payer: Heritage Provider Network Commercial |
$265.76
|
| Rate for Payer: Heritage Provider Network Senior |
$265.76
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$206.94
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$77.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$107.33
|
| Rate for Payer: Multiplan Commercial |
$322.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$364.93
|
| Rate for Payer: Vantage Medical Group Senior |
$364.93
|
|
|
PORACTANT ALFA 240 MG/3 ML INTRATRACHEAL SUSPENSION [117872]
|
Facility
IP
|
$429.33
|
|
|
Service Code
|
NDC 10122-510-03
|
| Hospital Charge Code |
1720929
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$77.71 |
| Max. Negotiated Rate |
$322.00 |
| Rate for Payer: Adventist Health Commercial |
$85.87
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$294.95
|
| Rate for Payer: Cash Price |
$193.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$231.84
|
| Rate for Payer: Heritage Provider Network Commercial |
$290.66
|
| Rate for Payer: Heritage Provider Network Senior |
$290.66
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$77.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$107.33
|
| Rate for Payer: Multiplan Commercial |
$322.00
|
|
|
PORFIMER 75 MG INTRAVENOUS SOLUTION [14472]
|
Facility
OP
|
$25,980.00
|
|
|
Service Code
|
CPT J9600
|
| Hospital Charge Code |
ERX14472
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4,702.38 |
| Max. Negotiated Rate |
$43,373.50 |
| Rate for Payer: Adventist Health Commercial |
$5,196.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$43,320.77
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$17,848.26
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$28,535.20
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$25,110.98
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$25,110.98
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,605.19
|
| Rate for Payer: Blue Shield of California Commercial |
$22,083.00
|
| Rate for Payer: Blue Shield of California EPN |
$22,083.00
|
| Rate for Payer: Cash Price |
$11,691.00
|
| Rate for Payer: Cash Price |
$11,691.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$11,950.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$34,242.24
|
| Rate for Payer: Dignity Health Medi-Cal |
$25,110.98
|
| Rate for Payer: Dignity Health Senior |
$25,110.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$16,627.20
|
| Rate for Payer: EPIC Health Plan Medicare |
$22,828.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$12,028.74
|
| Rate for Payer: Heritage Provider Network Senior |
$12,028.74
|
| Rate for Payer: Humana Medicare |
$22,828.16
|
| Rate for Payer: IEHP Medicare Advantage |
$22,828.16
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$43,373.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4,702.38
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$26,937.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6,495.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$28,763.48
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$28,763.48
|
| Rate for Payer: Multiplan Commercial |
$19,485.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$25,110.98
|
| Rate for Payer: TriValley Medical Group Senior |
$22,828.16
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$9,472.31
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$8,679.92
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$34,242.24
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$25,110.98
|
| Rate for Payer: Vantage Medical Group Senior |
$22,828.16
|
|
|
PORFIMER 75 MG INTRAVENOUS SOLUTION [14472]
|
Facility
IP
|
$25,980.00
|
|
|
Service Code
|
CPT J9600
|
| Hospital Charge Code |
ERX14472
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4,702.38 |
| Max. Negotiated Rate |
$19,485.00 |
| Rate for Payer: Adventist Health Commercial |
$5,196.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$17,848.26
|
| Rate for Payer: Cash Price |
$11,691.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$11,950.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$14,029.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$17,588.46
|
| Rate for Payer: Heritage Provider Network Senior |
$17,588.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4,702.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6,495.00
|
| Rate for Payer: Multiplan Commercial |
$19,485.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$9,472.31
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$8,679.92
|
|
|
POSACONAZOLE 100 MG TABLET,DELAYED RELEASE [204306]
|
Facility
OP
|
$9.00
|
|
|
Service Code
|
NDC 70748-258-07
|
| Hospital Charge Code |
ERX204306
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.63 |
| Max. Negotiated Rate |
$7.65 |
| Rate for Payer: Adventist Health Commercial |
$1.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$4.81
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.18
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$7.65
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4.95
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$6.75
|
| Rate for Payer: Blue Shield of California Commercial |
$5.59
|
| Rate for Payer: Blue Shield of California EPN |
$5.28
|
| Rate for Payer: Cash Price |
$4.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.85
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.65
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.65
|
| Rate for Payer: Dignity Health Senior |
$7.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.76
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.57
|
| Rate for Payer: Heritage Provider Network Senior |
$5.57
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.25
|
| Rate for Payer: Multiplan Commercial |
$6.75
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.65
|
| Rate for Payer: Vantage Medical Group Senior |
$7.65
|
|
|
POSACONAZOLE 100 MG TABLET,DELAYED RELEASE [204306]
|
Facility
OP
|
$82.24
|
|
|
Service Code
|
NDC 0085-4324-02
|
| Hospital Charge Code |
ERX204306
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$14.89 |
| Max. Negotiated Rate |
$69.90 |
| Rate for Payer: Adventist Health Commercial |
$16.45
|
| Rate for Payer: Aetna of CA Gatekeeper |
$43.96
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$56.50
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$69.90
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$45.23
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$61.68
|
| Rate for Payer: Blue Shield of California Commercial |
$51.07
|
| Rate for Payer: Blue Shield of California EPN |
$48.27
|
| Rate for Payer: Cash Price |
$37.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$53.46
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$69.90
|
| Rate for Payer: Dignity Health Medi-Cal |
$69.90
|
| Rate for Payer: Dignity Health Senior |
$69.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$52.63
|
| Rate for Payer: Heritage Provider Network Commercial |
$50.91
|
| Rate for Payer: Heritage Provider Network Senior |
$50.91
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$39.64
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$14.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$20.56
|
| Rate for Payer: Multiplan Commercial |
$61.68
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$69.90
|
| Rate for Payer: Vantage Medical Group Senior |
$69.90
|
|
|
POSACONAZOLE 100 MG TABLET,DELAYED RELEASE [204306]
|
Facility
IP
|
$82.24
|
|
|
Service Code
|
NDC 0085-4324-02
|
| Hospital Charge Code |
ERX204306
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$14.89 |
| Max. Negotiated Rate |
$61.68 |
| Rate for Payer: Adventist Health Commercial |
$16.45
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$56.50
|
| Rate for Payer: Cash Price |
$37.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$44.41
|
| Rate for Payer: Heritage Provider Network Commercial |
$55.68
|
| Rate for Payer: Heritage Provider Network Senior |
$55.68
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$14.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$20.56
|
| Rate for Payer: Multiplan Commercial |
$61.68
|
|
|
POSACONAZOLE 100 MG TABLET,DELAYED RELEASE [204306]
|
Facility
IP
|
$19.24
|
|
|
Service Code
|
NDC 0527-2133-35
|
| Hospital Charge Code |
ERX204306
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.48 |
| Max. Negotiated Rate |
$14.43 |
| Rate for Payer: Adventist Health Commercial |
$3.85
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$13.22
|
| Rate for Payer: Cash Price |
$8.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.39
|
| Rate for Payer: Heritage Provider Network Commercial |
$13.03
|
| Rate for Payer: Heritage Provider Network Senior |
$13.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.81
|
| Rate for Payer: Multiplan Commercial |
$14.43
|
|
|
POSACONAZOLE 100 MG TABLET,DELAYED RELEASE [204306]
|
Facility
OP
|
$56.60
|
|
|
Service Code
|
NDC 60687-523-21
|
| Hospital Charge Code |
ERX204306
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$10.24 |
| Max. Negotiated Rate |
$48.11 |
| Rate for Payer: Adventist Health Commercial |
$11.32
|
| Rate for Payer: Aetna of CA Gatekeeper |
$30.25
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$38.88
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$48.11
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$31.13
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$42.45
|
| Rate for Payer: Blue Shield of California Commercial |
$35.15
|
| Rate for Payer: Blue Shield of California EPN |
$33.22
|
| Rate for Payer: Cash Price |
$25.47
|
| Rate for Payer: Cigna of CA HMO/PPO |
$36.79
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$48.11
|
| Rate for Payer: Dignity Health Medi-Cal |
$48.11
|
| Rate for Payer: Dignity Health Senior |
$48.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$36.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$35.04
|
| Rate for Payer: Heritage Provider Network Senior |
$35.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$27.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.15
|
| Rate for Payer: Multiplan Commercial |
$42.45
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$48.11
|
| Rate for Payer: Vantage Medical Group Senior |
$48.11
|
|
|
POSACONAZOLE 100 MG TABLET,DELAYED RELEASE [204306]
|
Facility
IP
|
$56.60
|
|
|
Service Code
|
NDC 60687-523-21
|
| Hospital Charge Code |
ERX204306
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$10.24 |
| Max. Negotiated Rate |
$42.45 |
| Rate for Payer: Adventist Health Commercial |
$11.32
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$38.88
|
| Rate for Payer: Cash Price |
$25.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$30.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$38.32
|
| Rate for Payer: Heritage Provider Network Senior |
$38.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.15
|
| Rate for Payer: Multiplan Commercial |
$42.45
|
|
