|
CHROMIUM CHLORIDE 4 MCG/ML INTRAVENOUS SOLUTION [1685]
|
Facility
|
IP
|
$2.46
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.45 |
| Max. Negotiated Rate |
$1.84 |
| Rate for Payer: Adventist Health Commercial |
$0.49
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.58
|
| Rate for Payer: Cash Price |
$1.11
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.33
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.14
|
| Rate for Payer: Heritage Provider Network Senior |
$1.14
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.62
|
| Rate for Payer: Multiplan Commercial |
$1.84
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.89
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.81
|
|
|
CHROMIUM CHLORIDE 4 MCG/ML INTRAVENOUS SOLUTION [1685]
|
Facility
|
OP
|
$2.46
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.45 |
| Max. Negotiated Rate |
$2.09 |
| Rate for Payer: Adventist Health Commercial |
$0.49
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.52
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.35
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.84
|
| Rate for Payer: Blue Shield of California Commercial |
$1.50
|
| Rate for Payer: Blue Shield of California EPN |
$1.20
|
| Rate for Payer: Cash Price |
$1.11
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.13
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.09
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.57
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.14
|
| Rate for Payer: Heritage Provider Network Senior |
$1.14
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$1.17
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.62
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1.72
|
| Rate for Payer: Multiplan Commercial |
$1.84
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.98
|
| Rate for Payer: TriValley Medical Group Senior |
$0.98
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.89
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.81
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.09
|
| Rate for Payer: Vantage Medical Group Senior |
$2.09
|
|
|
CHROMOTUBATION OF OVIDUCT, INCLUDING MATERIALS
|
Facility
|
OP
|
$12,224.58
|
|
|
Service Code
|
CPT 58350
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,672.00 |
| Max. Negotiated Rate |
$12,224.58 |
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$9,650.99
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7,077.39
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$6,433.99
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,672.00
|
| Rate for Payer: Blue Shield of California Commercial |
$8,962.13
|
| Rate for Payer: Blue Shield of California EPN |
$7,178.49
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9,650.99
|
| Rate for Payer: Dignity Health Medi-Cal |
$7,077.39
|
| Rate for Payer: Dignity Health Medicare Advantage |
$6,433.99
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$6,433.99
|
| Rate for Payer: Heritage Provider Network Senior |
$7,913.81
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$6,433.99
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$12,224.58
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$7,399.09
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$8,621.55
|
| Rate for Payer: Multiplan WC |
$9,993.72
|
| Rate for Payer: TriValley Medical Group Commercial |
$7,077.39
|
| Rate for Payer: TriValley Medical Group Senior |
$7,077.39
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$10,001.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$8,445.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$9,650.99
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7,077.39
|
| Rate for Payer: Vantage Medical Group Senior |
$6,433.99
|
|
|
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC
|
Facility
|
IP
|
$13,646.25
|
|
|
Service Code
|
MSDRG 191
|
| Min. Negotiated Rate |
$10,183.77 |
| Max. Negotiated Rate |
$13,646.25 |
| Rate for Payer: EPIC Health Plan Medicare |
$10,183.77
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$10,183.77
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$11,711.34
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$13,646.25
|
|
|
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC
|
Facility
|
IP
|
$17,710.85
|
|
|
Service Code
|
MSDRG 190
|
| Min. Negotiated Rate |
$13,217.05 |
| Max. Negotiated Rate |
$17,710.85 |
| Rate for Payer: EPIC Health Plan Medicare |
$13,217.05
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$13,217.05
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$15,199.61
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$17,710.85
|
|
|
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC
|
Facility
|
IP
|
$10,559.79
|
|
|
Service Code
|
MSDRG 192
|
| Min. Negotiated Rate |
$7,880.44 |
| Max. Negotiated Rate |
$10,559.79 |
| Rate for Payer: EPIC Health Plan Medicare |
$7,880.44
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$7,880.44
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$9,062.51
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$10,559.79
|
|
|
C.I. ACID BLUE 90 0.025 % INTRAOCULAR SYRINGE [227971]
|
Facility
|
IP
|
$402.91
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$72.93 |
| Max. Negotiated Rate |
$302.18 |
| Rate for Payer: Adventist Health Commercial |
$80.58
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$259.47
|
| Rate for Payer: Cash Price |
$181.31
|
| Rate for Payer: Cigna of CA HMO/PPO |
$185.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$217.57
|
| Rate for Payer: Heritage Provider Network Commercial |
$186.55
|
| Rate for Payer: Heritage Provider Network Senior |
$186.55
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$72.93
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$100.73
|
| Rate for Payer: Multiplan Commercial |
$302.18
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$145.57
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$133.40
|
|
|
C.I. ACID BLUE 90 0.025 % INTRAOCULAR SYRINGE [227971]
|
Facility
|
OP
|
$402.91
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$72.93 |
| Max. Negotiated Rate |
$342.47 |
| Rate for Payer: Adventist Health Commercial |
$80.58
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$249.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$342.47
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$221.60
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$302.18
|
| Rate for Payer: Blue Shield of California Commercial |
$245.78
|
| Rate for Payer: Blue Shield of California EPN |
$196.62
|
| Rate for Payer: Cash Price |
$181.31
|
| Rate for Payer: Cigna of CA HMO/PPO |
$185.34
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$342.47
|
| Rate for Payer: Dignity Health Medi-Cal |
$342.47
|
| Rate for Payer: Dignity Health Medicare Advantage |
$342.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$257.86
|
| Rate for Payer: Heritage Provider Network Commercial |
$186.55
|
| Rate for Payer: Heritage Provider Network Senior |
$186.55
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$192.19
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$72.93
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$100.73
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$282.04
|
| Rate for Payer: Multiplan Commercial |
$302.18
|
| Rate for Payer: TriValley Medical Group Commercial |
$161.16
|
| Rate for Payer: TriValley Medical Group Senior |
$161.16
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$145.57
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$133.40
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$342.47
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$342.47
|
| Rate for Payer: Vantage Medical Group Senior |
$342.47
|
|
|
CICLOPIROX 0.77 % TOPICAL CREAM [9598]
|
Facility
|
OP
|
$1.08
|
|
|
Service Code
|
NDC 4580213811
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.92 |
| Rate for Payer: Adventist Health Commercial |
$0.22
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.67
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.92
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.59
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.81
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.54
|
| Rate for Payer: Blue Shield of California Commercial |
$0.66
|
| Rate for Payer: Blue Shield of California EPN |
$0.53
|
| Rate for Payer: Cash Price |
$0.49
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.70
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.92
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.92
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.69
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.67
|
| Rate for Payer: Heritage Provider Network Senior |
$0.67
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.52
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.27
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.76
|
| Rate for Payer: Multiplan Commercial |
$0.81
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.43
|
| Rate for Payer: TriValley Medical Group Senior |
$0.43
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.54
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.54
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.92
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.92
|
| Rate for Payer: Vantage Medical Group Senior |
$0.92
|
|
|
CICLOPIROX 0.77 % TOPICAL CREAM [9598]
|
Facility
|
IP
|
$1.08
|
|
|
Service Code
|
NDC 4580213811
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.81 |
| Rate for Payer: Adventist Health Commercial |
$0.22
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.70
|
| Rate for Payer: Cash Price |
$0.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.58
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.73
|
| Rate for Payer: Heritage Provider Network Senior |
$0.73
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.27
|
| Rate for Payer: Multiplan Commercial |
$0.81
|
|
|
CICLOPIROX 8 % TOPICAL SOLUTION [27158]
|
Facility
|
IP
|
$4.36
|
|
|
Service Code
|
NDC 4580214167
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.79 |
| Max. Negotiated Rate |
$3.27 |
| Rate for Payer: Adventist Health Commercial |
$0.87
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.81
|
| Rate for Payer: Cash Price |
$1.96
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.95
|
| Rate for Payer: Heritage Provider Network Senior |
$2.95
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.09
|
| Rate for Payer: Multiplan Commercial |
$3.27
|
|
|
CICLOPIROX 8 % TOPICAL SOLUTION [27158]
|
Facility
|
OP
|
$3.10
|
|
|
Service Code
|
NDC 2192205351
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$2.63 |
| Rate for Payer: Adventist Health Commercial |
$0.62
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.92
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.63
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.71
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.33
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.55
|
| Rate for Payer: Blue Shield of California Commercial |
$1.89
|
| Rate for Payer: Blue Shield of California EPN |
$1.51
|
| Rate for Payer: Cash Price |
$1.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.02
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.63
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.63
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.98
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.92
|
| Rate for Payer: Heritage Provider Network Senior |
$1.92
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$1.48
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.78
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$2.17
|
| Rate for Payer: Multiplan Commercial |
$2.33
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.24
|
| Rate for Payer: TriValley Medical Group Senior |
$1.24
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.55
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.55
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.63
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.63
|
| Rate for Payer: Vantage Medical Group Senior |
$2.63
|
|
|
CICLOPIROX 8 % TOPICAL SOLUTION [27158]
|
Facility
|
OP
|
$4.36
|
|
|
Service Code
|
NDC 4580214167
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.79 |
| Max. Negotiated Rate |
$3.71 |
| Rate for Payer: Adventist Health Commercial |
$0.87
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.69
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.71
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.40
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.27
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.18
|
| Rate for Payer: Blue Shield of California Commercial |
$2.66
|
| Rate for Payer: Blue Shield of California EPN |
$2.13
|
| Rate for Payer: Cash Price |
$1.96
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.83
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.71
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.71
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.79
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.70
|
| Rate for Payer: Heritage Provider Network Senior |
$2.70
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$2.08
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.09
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$3.05
|
| Rate for Payer: Multiplan Commercial |
$3.27
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.74
|
| Rate for Payer: TriValley Medical Group Senior |
$1.74
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.18
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.18
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.71
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.71
|
| Rate for Payer: Vantage Medical Group Senior |
$3.71
|
|
|
CICLOPIROX 8 % TOPICAL SOLUTION [27158]
|
Facility
|
IP
|
$3.10
|
|
|
Service Code
|
NDC 2192205351
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$2.33 |
| Rate for Payer: Adventist Health Commercial |
$0.62
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.00
|
| Rate for Payer: Cash Price |
$1.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.67
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.10
|
| Rate for Payer: Heritage Provider Network Senior |
$2.10
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.78
|
| Rate for Payer: Multiplan Commercial |
$2.33
|
|
|
CIDOFOVIR 10 MG/ML TOPICAL [4082503]
|
Facility
|
IP
|
$24.48
|
|
|
Service Code
|
NDC 9994082503
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.43 |
| Max. Negotiated Rate |
$18.36 |
| Rate for Payer: Adventist Health Commercial |
$4.90
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$15.77
|
| Rate for Payer: Cash Price |
$11.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$13.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$16.57
|
| Rate for Payer: Heritage Provider Network Senior |
$16.57
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$4.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.12
|
| Rate for Payer: Multiplan Commercial |
$18.36
|
|
|
CIDOFOVIR 10 MG/ML TOPICAL [4082503]
|
Facility
|
OP
|
$24.48
|
|
|
Service Code
|
NDC 9994082503
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.43 |
| Max. Negotiated Rate |
$20.81 |
| Rate for Payer: Adventist Health Commercial |
$4.90
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$15.13
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$20.81
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$13.46
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$18.36
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$12.24
|
| Rate for Payer: Blue Shield of California Commercial |
$14.93
|
| Rate for Payer: Blue Shield of California EPN |
$11.95
|
| Rate for Payer: Cash Price |
$11.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$15.91
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$20.81
|
| Rate for Payer: Dignity Health Medi-Cal |
$20.81
|
| Rate for Payer: Dignity Health Medicare Advantage |
$20.81
|
| Rate for Payer: EPIC Health Plan Commercial |
$15.67
|
| Rate for Payer: Heritage Provider Network Commercial |
$15.15
|
| Rate for Payer: Heritage Provider Network Senior |
$15.15
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$11.68
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$4.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.12
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$17.14
|
| Rate for Payer: Multiplan Commercial |
$18.36
|
| Rate for Payer: TriValley Medical Group Commercial |
$9.79
|
| Rate for Payer: TriValley Medical Group Senior |
$9.79
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$12.24
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$12.24
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$20.81
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$20.81
|
| Rate for Payer: Vantage Medical Group Senior |
$20.81
|
|
|
CIDOFOVIR 15 MG/ML TOPICAL [4081161]
|
Facility
|
IP
|
$36.53
|
|
|
Service Code
|
NDC 9999481161
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.61 |
| Max. Negotiated Rate |
$27.40 |
| Rate for Payer: Adventist Health Commercial |
$7.31
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$23.53
|
| Rate for Payer: Cash Price |
$16.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$19.73
|
| Rate for Payer: Heritage Provider Network Commercial |
$24.73
|
| Rate for Payer: Heritage Provider Network Senior |
$24.73
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$6.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.13
|
| Rate for Payer: Multiplan Commercial |
$27.40
|
|
|
CIDOFOVIR 15 MG/ML TOPICAL [4081161]
|
Facility
|
OP
|
$36.53
|
|
|
Service Code
|
NDC 9999481161
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.61 |
| Max. Negotiated Rate |
$31.05 |
| Rate for Payer: Adventist Health Commercial |
$7.31
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$22.58
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$31.05
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$20.09
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$27.40
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$18.27
|
| Rate for Payer: Blue Shield of California Commercial |
$22.28
|
| Rate for Payer: Blue Shield of California EPN |
$17.83
|
| Rate for Payer: Cash Price |
$16.44
|
| Rate for Payer: Cigna of CA HMO/PPO |
$23.74
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$31.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$31.05
|
| Rate for Payer: Dignity Health Medicare Advantage |
$31.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$23.38
|
| Rate for Payer: Heritage Provider Network Commercial |
$22.61
|
| Rate for Payer: Heritage Provider Network Senior |
$22.61
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$17.42
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$6.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.13
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$25.57
|
| Rate for Payer: Multiplan Commercial |
$27.40
|
| Rate for Payer: TriValley Medical Group Commercial |
$14.61
|
| Rate for Payer: TriValley Medical Group Senior |
$14.61
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$18.27
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$18.27
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$31.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$31.05
|
| Rate for Payer: Vantage Medical Group Senior |
$31.05
|
|
|
CIDOFOVIR 1 MG/ML TOPICAL [4081092]
|
Facility
|
OP
|
$36.53
|
|
|
Service Code
|
NDC 9999481192
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.61 |
| Max. Negotiated Rate |
$31.05 |
| Rate for Payer: Adventist Health Commercial |
$7.31
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$22.58
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$31.05
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$20.09
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$27.40
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$18.27
|
| Rate for Payer: Blue Shield of California Commercial |
$22.28
|
| Rate for Payer: Blue Shield of California EPN |
$17.83
|
| Rate for Payer: Cash Price |
$16.44
|
| Rate for Payer: Cigna of CA HMO/PPO |
$23.74
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$31.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$31.05
|
| Rate for Payer: Dignity Health Medicare Advantage |
$31.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$23.38
|
| Rate for Payer: Heritage Provider Network Commercial |
$22.61
|
| Rate for Payer: Heritage Provider Network Senior |
$22.61
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$17.42
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$6.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.13
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$25.57
|
| Rate for Payer: Multiplan Commercial |
$27.40
|
| Rate for Payer: TriValley Medical Group Commercial |
$14.61
|
| Rate for Payer: TriValley Medical Group Senior |
$14.61
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$18.27
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$18.27
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$31.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$31.05
|
| Rate for Payer: Vantage Medical Group Senior |
$31.05
|
|
|
CIDOFOVIR 1 MG/ML TOPICAL [4081092]
|
Facility
|
IP
|
$36.53
|
|
|
Service Code
|
NDC 9999481192
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.61 |
| Max. Negotiated Rate |
$27.40 |
| Rate for Payer: Adventist Health Commercial |
$7.31
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$23.53
|
| Rate for Payer: Cash Price |
$16.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$19.73
|
| Rate for Payer: Heritage Provider Network Commercial |
$24.73
|
| Rate for Payer: Heritage Provider Network Senior |
$24.73
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$6.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.13
|
| Rate for Payer: Multiplan Commercial |
$27.40
|
|
|
CIDOFOVIR 3 MG/ML TOPICAL [4081091]
|
Facility
|
IP
|
$36.53
|
|
|
Service Code
|
NDC 9999481191
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.61 |
| Max. Negotiated Rate |
$27.40 |
| Rate for Payer: Adventist Health Commercial |
$7.31
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$23.53
|
| Rate for Payer: Cash Price |
$16.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$19.73
|
| Rate for Payer: Heritage Provider Network Commercial |
$24.73
|
| Rate for Payer: Heritage Provider Network Senior |
$24.73
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$6.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.13
|
| Rate for Payer: Multiplan Commercial |
$27.40
|
|
|
CIDOFOVIR 3 MG/ML TOPICAL [4081091]
|
Facility
|
OP
|
$36.53
|
|
|
Service Code
|
NDC 9999481191
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.61 |
| Max. Negotiated Rate |
$31.05 |
| Rate for Payer: Adventist Health Commercial |
$7.31
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$22.58
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$31.05
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$20.09
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$27.40
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$18.27
|
| Rate for Payer: Blue Shield of California Commercial |
$22.28
|
| Rate for Payer: Blue Shield of California EPN |
$17.83
|
| Rate for Payer: Cash Price |
$16.44
|
| Rate for Payer: Cigna of CA HMO/PPO |
$23.74
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$31.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$31.05
|
| Rate for Payer: Dignity Health Medicare Advantage |
$31.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$23.38
|
| Rate for Payer: Heritage Provider Network Commercial |
$22.61
|
| Rate for Payer: Heritage Provider Network Senior |
$22.61
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$17.42
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$6.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.13
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$25.57
|
| Rate for Payer: Multiplan Commercial |
$27.40
|
| Rate for Payer: TriValley Medical Group Commercial |
$14.61
|
| Rate for Payer: TriValley Medical Group Senior |
$14.61
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$18.27
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$18.27
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$31.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$31.05
|
| Rate for Payer: Vantage Medical Group Senior |
$31.05
|
|
|
CIDOFOVIR 5 MG/ML TOPICAL [4081159]
|
Facility
|
IP
|
$36.53
|
|
|
Service Code
|
NDC 9999481159
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.61 |
| Max. Negotiated Rate |
$27.40 |
| Rate for Payer: Adventist Health Commercial |
$7.31
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$23.53
|
| Rate for Payer: Cash Price |
$16.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$19.73
|
| Rate for Payer: Heritage Provider Network Commercial |
$24.73
|
| Rate for Payer: Heritage Provider Network Senior |
$24.73
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$6.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.13
|
| Rate for Payer: Multiplan Commercial |
$27.40
|
|
|
CIDOFOVIR 5 MG/ML TOPICAL [4081159]
|
Facility
|
OP
|
$36.53
|
|
|
Service Code
|
NDC 9999481159
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.61 |
| Max. Negotiated Rate |
$31.05 |
| Rate for Payer: Adventist Health Commercial |
$7.31
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$22.58
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$31.05
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$20.09
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$27.40
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$18.27
|
| Rate for Payer: Blue Shield of California Commercial |
$22.28
|
| Rate for Payer: Blue Shield of California EPN |
$17.83
|
| Rate for Payer: Cash Price |
$16.44
|
| Rate for Payer: Cigna of CA HMO/PPO |
$23.74
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$31.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$31.05
|
| Rate for Payer: Dignity Health Medicare Advantage |
$31.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$23.38
|
| Rate for Payer: Heritage Provider Network Commercial |
$22.61
|
| Rate for Payer: Heritage Provider Network Senior |
$22.61
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$17.42
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$6.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.13
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$25.57
|
| Rate for Payer: Multiplan Commercial |
$27.40
|
| Rate for Payer: TriValley Medical Group Commercial |
$14.61
|
| Rate for Payer: TriValley Medical Group Senior |
$14.61
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$18.27
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$18.27
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$31.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$31.05
|
| Rate for Payer: Vantage Medical Group Senior |
$31.05
|
|
|
CIDOFOVIR 75 MG/ML INTRAVENOUS SOLUTION [17378]
|
Facility
|
OP
|
$237.29
|
|
|
Service Code
|
HCPCS J0740
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$42.95 |
| Max. Negotiated Rate |
$1,709.17 |
| Rate for Payer: Adventist Health Commercial |
$47.46
|
| Rate for Payer: Adventist Health Commercial |
$35.52
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$109.76
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$146.65
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$669.67
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$669.67
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$589.31
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$589.31
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$589.31
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$589.31
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,709.17
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,709.17
|
| Rate for Payer: Blue Shield of California Commercial |
$881.65
|
| Rate for Payer: Blue Shield of California Commercial |
$881.65
|
| Rate for Payer: Blue Shield of California EPN |
$881.65
|
| Rate for Payer: Blue Shield of California EPN |
$881.65
|
| Rate for Payer: Cash Price |
$106.78
|
| Rate for Payer: Cash Price |
$106.78
|
| Rate for Payer: Cash Price |
$79.92
|
| Rate for Payer: Cash Price |
$79.92
|
| Rate for Payer: Cigna of CA HMO/PPO |
$109.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$81.70
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$669.67
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$669.67
|
| Rate for Payer: Dignity Health Medi-Cal |
$589.31
|
| Rate for Payer: Dignity Health Medi-Cal |
$589.31
|
| Rate for Payer: Dignity Health Medicare Advantage |
$589.31
|
| Rate for Payer: Dignity Health Medicare Advantage |
$589.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$151.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$113.66
|
| Rate for Payer: EPIC Health Plan Medicare |
$535.74
|
| Rate for Payer: EPIC Health Plan Medicare |
$535.74
|
| Rate for Payer: Heritage Provider Network Commercial |
$109.87
|
| Rate for Payer: Heritage Provider Network Commercial |
$82.23
|
| Rate for Payer: Heritage Provider Network Senior |
$109.87
|
| Rate for Payer: Heritage Provider Network Senior |
$82.23
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$535.74
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$535.74
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$113.19
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$84.72
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$32.15
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$42.95
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$616.10
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$616.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$59.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$44.40
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$717.89
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$717.89
|
| Rate for Payer: Multiplan Commercial |
$177.97
|
| Rate for Payer: Multiplan Commercial |
$133.20
|
| Rate for Payer: TriValley Medical Group Commercial |
$71.04
|
| Rate for Payer: TriValley Medical Group Commercial |
$94.92
|
| Rate for Payer: TriValley Medical Group Senior |
$71.04
|
| Rate for Payer: TriValley Medical Group Senior |
$94.92
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$85.73
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$64.17
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$78.57
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$58.80
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$669.67
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$669.67
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$589.31
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$589.31
|
| Rate for Payer: Vantage Medical Group Senior |
$589.31
|
| Rate for Payer: Vantage Medical Group Senior |
$589.31
|
|
