|
ELETRIPTAN 40 MG TABLET [34684]
|
Facility
|
OP
|
$92.31
|
|
|
Service Code
|
NDC 0049-2340-45
|
| Hospital Charge Code |
1711914
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$16.71 |
| Max. Negotiated Rate |
$78.46 |
| Rate for Payer: Adventist Health Commercial |
$18.46
|
| Rate for Payer: Aetna of CA Gatekeeper |
$49.34
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$63.42
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$78.46
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$50.77
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$69.23
|
| Rate for Payer: Blue Shield of California Commercial |
$57.32
|
| Rate for Payer: Blue Shield of California EPN |
$54.19
|
| Rate for Payer: Cash Price |
$41.54
|
| Rate for Payer: Cigna of CA HMO/PPO |
$60.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$78.46
|
| Rate for Payer: Dignity Health Medi-Cal |
$78.46
|
| Rate for Payer: Dignity Health Senior |
$78.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$59.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$57.14
|
| Rate for Payer: Heritage Provider Network Senior |
$57.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$44.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$16.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$23.08
|
| Rate for Payer: Multiplan Commercial |
$69.23
|
| Rate for Payer: TriValley Medical Group Commercial |
$36.92
|
| Rate for Payer: TriValley Medical Group Senior |
$36.92
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$78.46
|
| Rate for Payer: Vantage Medical Group Senior |
$78.46
|
|
|
ELOTUZUMAB 300 MG INTRAVENOUS SOLUTION [212322]
|
Facility
|
IP
|
$2,573.28
|
|
|
Service Code
|
NDC 0003-2291-11
|
| Hospital Charge Code |
ERX212322
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$465.76 |
| Max. Negotiated Rate |
$1,929.96 |
| Rate for Payer: Adventist Health Commercial |
$514.66
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,767.84
|
| Rate for Payer: Cash Price |
$1,157.98
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,183.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,389.57
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,742.11
|
| Rate for Payer: Heritage Provider Network Senior |
$1,742.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$465.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$643.32
|
| Rate for Payer: Multiplan Commercial |
$1,929.96
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$938.22
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$859.73
|
|
|
ELOTUZUMAB 300 MG INTRAVENOUS SOLUTION [212322]
|
Facility
|
OP
|
$2,573.28
|
|
|
Service Code
|
NDC 0003-2291-11
|
| Hospital Charge Code |
ERX212322
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$465.76 |
| Max. Negotiated Rate |
$2,187.29 |
| Rate for Payer: Adventist Health Commercial |
$514.66
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,375.42
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,767.84
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2,187.29
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,415.30
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,929.96
|
| Rate for Payer: Blue Shield of California Commercial |
$1,598.01
|
| Rate for Payer: Blue Shield of California EPN |
$1,510.52
|
| Rate for Payer: Cash Price |
$1,157.98
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,183.71
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2,187.29
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,187.29
|
| Rate for Payer: Dignity Health Senior |
$2,187.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,646.90
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,191.43
|
| Rate for Payer: Heritage Provider Network Senior |
$1,191.43
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,240.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$465.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$643.32
|
| Rate for Payer: Multiplan Commercial |
$1,929.96
|
| Rate for Payer: TriValley Medical Group Commercial |
$1,029.31
|
| Rate for Payer: TriValley Medical Group Senior |
$1,029.31
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$938.22
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$859.73
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,187.29
|
| Rate for Payer: Vantage Medical Group Senior |
$2,187.29
|
|
|
ELOTUZUMAB 400 MG INTRAVENOUS SOLUTION [212323]
|
Facility
|
OP
|
$3,431.02
|
|
|
Service Code
|
CPT J9176
|
| Hospital Charge Code |
ERX212323
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.00 |
| Max. Negotiated Rate |
$2,573.26 |
| Rate for Payer: Adventist Health Commercial |
$686.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$14.53
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,357.11
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$9.22
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$8.12
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$12.60
|
| Rate for Payer: Blue Shield of California Commercial |
$7.00
|
| Rate for Payer: Blue Shield of California EPN |
$7.00
|
| Rate for Payer: Cash Price |
$1,543.96
|
| Rate for Payer: Cash Price |
$1,543.96
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,578.27
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$8.12
|
| Rate for Payer: Dignity Health Senior |
$8.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,195.85
|
| Rate for Payer: EPIC Health Plan Medicare |
$7.38
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,588.56
|
| Rate for Payer: Heritage Provider Network Senior |
$1,588.56
|
| Rate for Payer: Humana Medicare |
$7.38
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$18.47
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$7.38
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$14.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$621.01
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$8.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$857.76
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$9.30
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$9.30
|
| Rate for Payer: Multiplan Commercial |
$2,573.26
|
| Rate for Payer: TriValley Medical Group Commercial |
$1,372.41
|
| Rate for Payer: TriValley Medical Group Senior |
$1,372.41
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,250.95
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,146.30
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$11.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8.12
|
| Rate for Payer: Vantage Medical Group Senior |
$7.38
|
|
|
ELOTUZUMAB 400 MG INTRAVENOUS SOLUTION [212323]
|
Facility
|
IP
|
$3,431.02
|
|
|
Service Code
|
CPT J9176
|
| Hospital Charge Code |
ERX212323
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$621.01 |
| Max. Negotiated Rate |
$2,573.26 |
| Rate for Payer: Adventist Health Commercial |
$686.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,357.11
|
| Rate for Payer: Cash Price |
$1,543.96
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,578.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,852.75
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,322.80
|
| Rate for Payer: Heritage Provider Network Senior |
$2,322.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$621.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$857.76
|
| Rate for Payer: Multiplan Commercial |
$2,573.26
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,250.95
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,146.30
|
|
|
ELTROMBOPAG OLAMINE 25 MG TABLET [94579]
|
Facility
|
OP
|
$268.39
|
|
|
Service Code
|
NDC 0078-0685-15
|
| Hospital Charge Code |
ERX94579
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$48.58 |
| Max. Negotiated Rate |
$228.13 |
| Rate for Payer: Adventist Health Commercial |
$53.68
|
| Rate for Payer: Aetna of CA Gatekeeper |
$143.45
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$184.38
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$228.13
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$147.61
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$201.29
|
| Rate for Payer: Blue Shield of California Commercial |
$166.67
|
| Rate for Payer: Blue Shield of California EPN |
$157.54
|
| Rate for Payer: Cash Price |
$120.78
|
| Rate for Payer: Cigna of CA HMO/PPO |
$174.45
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$228.13
|
| Rate for Payer: Dignity Health Medi-Cal |
$228.13
|
| Rate for Payer: Dignity Health Senior |
$228.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$171.77
|
| Rate for Payer: Heritage Provider Network Commercial |
$166.13
|
| Rate for Payer: Heritage Provider Network Senior |
$166.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$129.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$48.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$67.10
|
| Rate for Payer: Multiplan Commercial |
$201.29
|
| Rate for Payer: TriValley Medical Group Commercial |
$107.36
|
| Rate for Payer: TriValley Medical Group Senior |
$107.36
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$228.13
|
| Rate for Payer: Vantage Medical Group Senior |
$228.13
|
|
|
ELTROMBOPAG OLAMINE 25 MG TABLET [94579]
|
Facility
|
IP
|
$268.39
|
|
|
Service Code
|
NDC 0078-0685-15
|
| Hospital Charge Code |
ERX94579
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$48.58 |
| Max. Negotiated Rate |
$201.29 |
| Rate for Payer: Adventist Health Commercial |
$53.68
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$184.38
|
| Rate for Payer: Cash Price |
$120.78
|
| Rate for Payer: EPIC Health Plan Commercial |
$144.93
|
| Rate for Payer: Heritage Provider Network Commercial |
$181.70
|
| Rate for Payer: Heritage Provider Network Senior |
$181.70
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$48.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$67.10
|
| Rate for Payer: Multiplan Commercial |
$201.29
|
|
|
ELTROMBOPAG OLAMINE 50 MG TABLET [94580]
|
Facility
|
IP
|
$485.71
|
|
|
Service Code
|
NDC 0078-0686-15
|
| Hospital Charge Code |
ERX94580
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$87.91 |
| Max. Negotiated Rate |
$364.28 |
| Rate for Payer: Adventist Health Commercial |
$97.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$333.68
|
| Rate for Payer: Cash Price |
$218.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$262.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$328.83
|
| Rate for Payer: Heritage Provider Network Senior |
$328.83
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$87.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$121.43
|
| Rate for Payer: Multiplan Commercial |
$364.28
|
|
|
ELTROMBOPAG OLAMINE 50 MG TABLET [94580]
|
Facility
|
OP
|
$485.71
|
|
|
Service Code
|
NDC 0078-0686-15
|
| Hospital Charge Code |
ERX94580
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$87.91 |
| Max. Negotiated Rate |
$412.85 |
| Rate for Payer: Adventist Health Commercial |
$97.14
|
| Rate for Payer: Aetna of CA Gatekeeper |
$259.61
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$333.68
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$412.85
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$267.14
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$364.28
|
| Rate for Payer: Blue Shield of California Commercial |
$301.63
|
| Rate for Payer: Blue Shield of California EPN |
$285.11
|
| Rate for Payer: Cash Price |
$218.57
|
| Rate for Payer: Cigna of CA HMO/PPO |
$315.71
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$412.85
|
| Rate for Payer: Dignity Health Medi-Cal |
$412.85
|
| Rate for Payer: Dignity Health Senior |
$412.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$310.85
|
| Rate for Payer: Heritage Provider Network Commercial |
$300.65
|
| Rate for Payer: Heritage Provider Network Senior |
$300.65
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$234.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$87.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$121.43
|
| Rate for Payer: Multiplan Commercial |
$364.28
|
| Rate for Payer: TriValley Medical Group Commercial |
$194.28
|
| Rate for Payer: TriValley Medical Group Senior |
$194.28
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$412.85
|
| Rate for Payer: Vantage Medical Group Senior |
$412.85
|
|
|
EMAPALUMAB-LZSG 5 MG/ML INTRAVENOUS SOLUTION [223872]
|
Facility
|
OP
|
$2,026.21
|
|
|
Service Code
|
CPT J9210
|
| Hospital Charge Code |
NDG223872A
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$344.45 |
| Max. Negotiated Rate |
$1,519.66 |
| Rate for Payer: Adventist Health Commercial |
$405.24
|
| Rate for Payer: Aetna of CA Gatekeeper |
$922.84
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,392.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$469.57
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$413.22
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$413.22
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$721.71
|
| Rate for Payer: Blue Shield of California Commercial |
$344.45
|
| Rate for Payer: Blue Shield of California EPN |
$344.45
|
| Rate for Payer: Cash Price |
$911.79
|
| Rate for Payer: Cash Price |
$911.79
|
| Rate for Payer: Cigna of CA HMO/PPO |
$932.06
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$469.57
|
| Rate for Payer: Dignity Health Medi-Cal |
$413.22
|
| Rate for Payer: Dignity Health Senior |
$413.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,296.77
|
| Rate for Payer: EPIC Health Plan Medicare |
$375.66
|
| Rate for Payer: Heritage Provider Network Commercial |
$938.14
|
| Rate for Payer: Heritage Provider Network Senior |
$938.14
|
| Rate for Payer: Humana Medicare |
$375.66
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$592.99
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$375.66
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$713.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$366.74
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$443.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$506.55
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$473.33
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$473.33
|
| Rate for Payer: Multiplan Commercial |
$1,519.66
|
| Rate for Payer: TriValley Medical Group Commercial |
$810.48
|
| Rate for Payer: TriValley Medical Group Senior |
$810.48
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$738.76
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$676.96
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$469.57
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$413.22
|
| Rate for Payer: Vantage Medical Group Senior |
$413.22
|
|
|
EMAPALUMAB-LZSG 5 MG/ML INTRAVENOUS SOLUTION [223872]
|
Facility
|
IP
|
$2,026.21
|
|
|
Service Code
|
CPT J9210
|
| Hospital Charge Code |
NDG223872A
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$366.74 |
| Max. Negotiated Rate |
$1,519.66 |
| Rate for Payer: Adventist Health Commercial |
$405.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,392.01
|
| Rate for Payer: Cash Price |
$911.79
|
| Rate for Payer: Cigna of CA HMO/PPO |
$932.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,094.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,371.74
|
| Rate for Payer: Heritage Provider Network Senior |
$1,371.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$366.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$506.55
|
| Rate for Payer: Multiplan Commercial |
$1,519.66
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$738.76
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$676.96
|
|
|
EMOLLIENT COMBINATION NO.10 TOPICAL EMULSION [42944]
|
Facility
|
IP
|
$1.33
|
|
|
Service Code
|
NDC 0187-5110-45
|
| Hospital Charge Code |
1743698
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$1.00 |
| Rate for Payer: Adventist Health Commercial |
$0.27
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.91
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.72
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.90
|
| Rate for Payer: Heritage Provider Network Senior |
$0.90
|
| 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 |
$1.00
|
|
|
EMOLLIENT COMBINATION NO.10 TOPICAL EMULSION [42944]
|
Facility
|
IP
|
$0.58
|
|
|
Service Code
|
NDC 5898096012
|
| Hospital Charge Code |
1743698
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.44 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.40
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.31
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.39
|
| Rate for Payer: Heritage Provider Network Senior |
$0.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.44
|
|
|
EMOLLIENT COMBINATION NO.10 TOPICAL EMULSION [42944]
|
Facility
|
OP
|
$0.58
|
|
|
Service Code
|
NDC 5898096012
|
| Hospital Charge Code |
1743698
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.49 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.31
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.40
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.49
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.32
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.44
|
| Rate for Payer: Blue Shield of California Commercial |
$0.36
|
| Rate for Payer: Blue Shield of California EPN |
$0.34
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.38
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.49
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.49
|
| Rate for Payer: Dignity Health Senior |
$0.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.37
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.36
|
| Rate for Payer: Heritage Provider Network Senior |
$0.36
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.44
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.23
|
| Rate for Payer: TriValley Medical Group Senior |
$0.23
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.49
|
| Rate for Payer: Vantage Medical Group Senior |
$0.49
|
|
|
EMOLLIENT COMBINATION NO.10 TOPICAL EMULSION [42944]
|
Facility
|
OP
|
$1.33
|
|
|
Service Code
|
NDC 0187-5110-45
|
| Hospital Charge Code |
1743698
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$1.13 |
| Rate for Payer: Adventist Health Commercial |
$0.27
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.71
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.91
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.13
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.73
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.00
|
| Rate for Payer: Blue Shield of California Commercial |
$0.83
|
| Rate for Payer: Blue Shield of California EPN |
$0.78
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.86
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.13
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.13
|
| Rate for Payer: Dignity Health Senior |
$1.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.85
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.82
|
| Rate for Payer: Heritage Provider Network Senior |
$0.82
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.64
|
| 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 |
$1.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.53
|
| Rate for Payer: TriValley Medical Group Senior |
$0.53
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.13
|
| Rate for Payer: Vantage Medical Group Senior |
$1.13
|
|
|
EMOLLIENT COMBINATION NO.69 TOPICAL CREAM [196535]
|
Facility
|
OP
|
$0.03
|
|
|
Service Code
|
NDC 7214063378
|
| Hospital Charge Code |
NDG196535A
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.02
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.03
|
| Rate for Payer: Dignity Health Senior |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Senior |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.01
|
| Rate for Payer: TriValley Medical Group Senior |
$0.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Vantage Medical Group Senior |
$0.03
|
|
|
EMOLLIENT COMBINATION NO.69 TOPICAL CREAM [196535]
|
Facility
|
IP
|
$0.03
|
|
|
Service Code
|
NDC 7214063378
|
| Hospital Charge Code |
NDG196535A
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.02
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Senior |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
|
|
EMOLLIENTS BAG BALM OINTMENT [4080770]
|
Facility
|
OP
|
$35.74
|
|
|
Service Code
|
NDC 98193-000-17
|
| Hospital Charge Code |
NDG4080770
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.47 |
| Max. Negotiated Rate |
$30.38 |
| Rate for Payer: Adventist Health Commercial |
$7.15
|
| Rate for Payer: Aetna of CA Gatekeeper |
$19.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$24.55
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$30.38
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$19.66
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$26.80
|
| Rate for Payer: Blue Shield of California Commercial |
$22.19
|
| Rate for Payer: Blue Shield of California EPN |
$20.98
|
| Rate for Payer: Cash Price |
$16.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$23.23
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$30.38
|
| Rate for Payer: Dignity Health Medi-Cal |
$30.38
|
| Rate for Payer: Dignity Health Senior |
$30.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$22.87
|
| Rate for Payer: Heritage Provider Network Commercial |
$22.12
|
| Rate for Payer: Heritage Provider Network Senior |
$22.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$17.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.94
|
| Rate for Payer: Multiplan Commercial |
$26.80
|
| Rate for Payer: TriValley Medical Group Commercial |
$14.30
|
| Rate for Payer: TriValley Medical Group Senior |
$14.30
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$30.38
|
| Rate for Payer: Vantage Medical Group Senior |
$30.38
|
|
|
EMOLLIENTS BAG BALM OINTMENT [4080770]
|
Facility
|
IP
|
$5.11
|
|
|
Service Code
|
NDC 99408-770-02
|
| Hospital Charge Code |
1743780
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.92 |
| Max. Negotiated Rate |
$3.83 |
| Rate for Payer: Adventist Health Commercial |
$1.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.51
|
| Rate for Payer: Cash Price |
$2.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.76
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.46
|
| Rate for Payer: Heritage Provider Network Senior |
$3.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.28
|
| Rate for Payer: Multiplan Commercial |
$3.83
|
|
|
EMOLLIENTS BAG BALM OINTMENT [4080770]
|
Facility
|
IP
|
$35.74
|
|
|
Service Code
|
NDC 98193-000-17
|
| Hospital Charge Code |
NDG4080770
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.47 |
| Max. Negotiated Rate |
$26.80 |
| Rate for Payer: Adventist Health Commercial |
$7.15
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$24.55
|
| Rate for Payer: Cash Price |
$16.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$19.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$24.20
|
| Rate for Payer: Heritage Provider Network Senior |
$24.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.94
|
| Rate for Payer: Multiplan Commercial |
$26.80
|
|
|
EMOLLIENTS BAG BALM OINTMENT [4080770]
|
Facility
|
OP
|
$3.36
|
|
|
Service Code
|
NDC 9994-0807-70
|
| Hospital Charge Code |
1743584
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$2.86 |
| Rate for Payer: Adventist Health Commercial |
$0.67
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.31
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.86
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.85
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.52
|
| Rate for Payer: Blue Shield of California Commercial |
$2.09
|
| Rate for Payer: Blue Shield of California EPN |
$1.97
|
| Rate for Payer: Cash Price |
$1.51
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.86
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.86
|
| Rate for Payer: Dignity Health Senior |
$2.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.08
|
| Rate for Payer: Heritage Provider Network Senior |
$2.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.84
|
| Rate for Payer: Multiplan Commercial |
$2.52
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.34
|
| Rate for Payer: TriValley Medical Group Senior |
$1.34
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.86
|
| Rate for Payer: Vantage Medical Group Senior |
$2.86
|
|
|
EMOLLIENTS BAG BALM OINTMENT [4080770]
|
Facility
|
OP
|
$5.11
|
|
|
Service Code
|
NDC 99408-770-02
|
| Hospital Charge Code |
1743780
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.92 |
| Max. Negotiated Rate |
$4.34 |
| Rate for Payer: Adventist Health Commercial |
$1.02
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.73
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.51
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.34
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.81
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.83
|
| Rate for Payer: Blue Shield of California Commercial |
$3.17
|
| Rate for Payer: Blue Shield of California EPN |
$3.00
|
| Rate for Payer: Cash Price |
$2.30
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.34
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.34
|
| Rate for Payer: Dignity Health Senior |
$4.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.27
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.16
|
| Rate for Payer: Heritage Provider Network Senior |
$3.16
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.28
|
| Rate for Payer: Multiplan Commercial |
$3.83
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.04
|
| Rate for Payer: TriValley Medical Group Senior |
$2.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.34
|
| Rate for Payer: Vantage Medical Group Senior |
$4.34
|
|
|
EMOLLIENTS BAG BALM OINTMENT [4080770]
|
Facility
|
IP
|
$3.36
|
|
|
Service Code
|
NDC 9994-0807-70
|
| Hospital Charge Code |
1743584
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$2.52 |
| Rate for Payer: Adventist Health Commercial |
$0.67
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.31
|
| Rate for Payer: Cash Price |
$1.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.81
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.27
|
| Rate for Payer: Heritage Provider Network Senior |
$2.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.84
|
| Rate for Payer: Multiplan Commercial |
$2.52
|
|
|
EMOLLIENTS BAG BALM OINTMENT [4080770]
|
Facility
|
IP
|
$4.73
|
|
|
Service Code
|
NDC 98193-00005
|
| Hospital Charge Code |
NDG4080770B
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.86 |
| Max. Negotiated Rate |
$3.55 |
| Rate for Payer: Adventist Health Commercial |
$0.95
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.25
|
| Rate for Payer: Cash Price |
$2.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.20
|
| Rate for Payer: Heritage Provider Network Senior |
$3.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.18
|
| Rate for Payer: Multiplan Commercial |
$3.55
|
|
|
EMOLLIENTS BAG BALM OINTMENT [4080770]
|
Facility
|
OP
|
$4.73
|
|
|
Service Code
|
NDC 98193-00005
|
| Hospital Charge Code |
NDG4080770B
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.86 |
| Max. Negotiated Rate |
$4.02 |
| Rate for Payer: Adventist Health Commercial |
$0.95
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.53
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.25
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.02
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.60
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.55
|
| Rate for Payer: Blue Shield of California Commercial |
$2.94
|
| Rate for Payer: Blue Shield of California EPN |
$2.78
|
| Rate for Payer: Cash Price |
$2.13
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.02
|
| Rate for Payer: Dignity Health Senior |
$4.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.93
|
| Rate for Payer: Heritage Provider Network Senior |
$2.93
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.18
|
| Rate for Payer: Multiplan Commercial |
$3.55
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.89
|
| Rate for Payer: TriValley Medical Group Senior |
$1.89
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.02
|
| Rate for Payer: Vantage Medical Group Senior |
$4.02
|
|
