|
ELETRIPTAN 20 MG TABLET [34683]
|
Facility
|
IP
|
$96.92
|
|
|
Service Code
|
NDC 0049233045
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$17.54 |
| Max. Negotiated Rate |
$72.69 |
| Rate for Payer: Adventist Health Commercial |
$19.38
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$62.42
|
| Rate for Payer: Cash Price |
$43.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$52.34
|
| Rate for Payer: Heritage Provider Network Commercial |
$65.61
|
| Rate for Payer: Heritage Provider Network Senior |
$65.61
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$17.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$24.23
|
| Rate for Payer: Multiplan Commercial |
$72.69
|
|
|
ELOTUZUMAB 300 MG INTRAVENOUS SOLUTION [212322]
|
Facility
|
IP
|
$2,841.11
|
|
|
Service Code
|
HCPCS J9176
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$514.24 |
| Max. Negotiated Rate |
$2,130.83 |
| Rate for Payer: Adventist Health Commercial |
$568.22
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,829.67
|
| Rate for Payer: Cash Price |
$1,278.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,306.91
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,534.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,315.43
|
| Rate for Payer: Heritage Provider Network Senior |
$1,315.43
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$514.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$710.28
|
| Rate for Payer: Multiplan Commercial |
$2,130.83
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,026.49
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$940.69
|
|
|
ELOTUZUMAB 300 MG INTRAVENOUS SOLUTION [212322]
|
Facility
|
OP
|
$2,841.11
|
|
|
Service Code
|
HCPCS J9176
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.58 |
| Max. Negotiated Rate |
$2,130.83 |
| Rate for Payer: Blue Shield of California EPN |
$7.58
|
| Rate for Payer: Cash Price |
$1,278.50
|
| Rate for Payer: Adventist Health Commercial |
$568.22
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,755.81
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$12.29
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$9.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$8.19
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$14.30
|
| Rate for Payer: Blue Shield of California Commercial |
$7.58
|
| Rate for Payer: Cash Price |
$1,278.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,306.91
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10.24
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.01
|
| Rate for Payer: Dignity Health Medicare Advantage |
$9.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,818.31
|
| Rate for Payer: EPIC Health Plan Medicare |
$8.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,315.43
|
| Rate for Payer: Heritage Provider Network Senior |
$1,315.43
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$8.19
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$1,355.21
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$514.24
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$9.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$710.28
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$10.97
|
| Rate for Payer: Multiplan Commercial |
$2,130.83
|
| Rate for Payer: TriValley Medical Group Commercial |
$1,136.44
|
| Rate for Payer: TriValley Medical Group Senior |
$1,136.44
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,026.49
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$940.69
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$10.24
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.01
|
| Rate for Payer: Vantage Medical Group Senior |
$9.01
|
|
|
ELOTUZUMAB 400 MG INTRAVENOUS SOLUTION [212323]
|
Facility
|
IP
|
$3,788.11
|
|
|
Service Code
|
HCPCS J9176
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$685.65 |
| Max. Negotiated Rate |
$2,841.08 |
| Rate for Payer: Adventist Health Commercial |
$757.62
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,439.54
|
| Rate for Payer: Cash Price |
$1,704.65
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,742.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,045.58
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,753.89
|
| Rate for Payer: Heritage Provider Network Senior |
$1,753.89
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$685.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$947.03
|
| Rate for Payer: Multiplan Commercial |
$2,841.08
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,368.64
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,254.24
|
|
|
ELOTUZUMAB 400 MG INTRAVENOUS SOLUTION [212323]
|
Facility
|
OP
|
$3,788.11
|
|
|
Service Code
|
HCPCS J9176
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.58 |
| Max. Negotiated Rate |
$2,841.08 |
| Rate for Payer: Adventist Health Commercial |
$757.62
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,341.05
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$12.29
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$9.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$8.19
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$14.30
|
| Rate for Payer: Blue Shield of California Commercial |
$7.58
|
| Rate for Payer: Blue Shield of California EPN |
$7.58
|
| Rate for Payer: Cash Price |
$1,704.65
|
| Rate for Payer: Cash Price |
$1,704.65
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,742.53
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10.24
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.01
|
| Rate for Payer: Dignity Health Medicare Advantage |
$9.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,424.39
|
| Rate for Payer: EPIC Health Plan Medicare |
$8.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,753.89
|
| Rate for Payer: Heritage Provider Network Senior |
$1,753.89
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$8.19
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$1,806.93
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$685.65
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$9.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$947.03
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$10.97
|
| Rate for Payer: Multiplan Commercial |
$2,841.08
|
| Rate for Payer: TriValley Medical Group Commercial |
$1,515.24
|
| Rate for Payer: TriValley Medical Group Senior |
$1,515.24
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,368.64
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,254.24
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$10.24
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.01
|
| Rate for Payer: Vantage Medical Group Senior |
$9.01
|
|
|
ELRANATAMAB-BCMM 40 MG/ML SUBCUTANEOUS SOLUTION [239200]
|
Facility
|
IP
|
$9,759.06
|
|
|
Service Code
|
HCPCS J1323
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,766.39 |
| Max. Negotiated Rate |
$7,319.30 |
| Rate for Payer: Adventist Health Commercial |
$1,951.81
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6,284.83
|
| Rate for Payer: Cash Price |
$4,391.58
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4,489.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$5,269.89
|
| Rate for Payer: Heritage Provider Network Commercial |
$4,518.44
|
| Rate for Payer: Heritage Provider Network Senior |
$4,518.44
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1,766.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,439.76
|
| Rate for Payer: Multiplan Commercial |
$7,319.30
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3,525.95
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3,231.22
|
|
|
ELRANATAMAB-BCMM 40 MG/ML SUBCUTANEOUS SOLUTION [239200]
|
Facility
|
OP
|
$9,759.06
|
|
|
Service Code
|
HCPCS J1323
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$181.99 |
| Max. Negotiated Rate |
$7,319.30 |
| Rate for Payer: Adventist Health Commercial |
$1,951.81
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6,031.10
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$240.60
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$211.73
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$211.73
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$416.22
|
| Rate for Payer: Blue Shield of California Commercial |
$181.99
|
| Rate for Payer: Blue Shield of California EPN |
$181.99
|
| Rate for Payer: Cash Price |
$4,391.58
|
| Rate for Payer: Cash Price |
$4,391.58
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4,489.17
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$240.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$211.73
|
| Rate for Payer: Dignity Health Medicare Advantage |
$211.73
|
| Rate for Payer: EPIC Health Plan Commercial |
$6,245.80
|
| Rate for Payer: EPIC Health Plan Medicare |
$192.48
|
| Rate for Payer: Heritage Provider Network Commercial |
$4,518.44
|
| Rate for Payer: Heritage Provider Network Senior |
$4,518.44
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$192.48
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$4,655.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1,766.39
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$221.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,439.76
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$257.92
|
| Rate for Payer: Multiplan Commercial |
$7,319.30
|
| Rate for Payer: TriValley Medical Group Commercial |
$3,903.62
|
| Rate for Payer: TriValley Medical Group Senior |
$3,903.62
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3,525.95
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3,231.22
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$240.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$211.73
|
| Rate for Payer: Vantage Medical Group Senior |
$211.73
|
|
|
ELTROMBOPAG OLAMINE 25 MG TABLET [94579]
|
Facility
|
OP
|
$313.06
|
|
|
Service Code
|
NDC 0078068515
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$56.66 |
| Max. Negotiated Rate |
$266.10 |
| Rate for Payer: Adventist Health Commercial |
$62.61
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$193.47
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$266.10
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$172.18
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$234.79
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$156.59
|
| Rate for Payer: Blue Shield of California Commercial |
$190.97
|
| Rate for Payer: Blue Shield of California EPN |
$152.77
|
| Rate for Payer: Cash Price |
$140.88
|
| Rate for Payer: Cigna of CA HMO/PPO |
$203.49
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$266.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$266.10
|
| Rate for Payer: Dignity Health Medicare Advantage |
$266.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$200.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$193.78
|
| Rate for Payer: Heritage Provider Network Senior |
$193.78
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$149.33
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$56.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$78.27
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$219.14
|
| Rate for Payer: Multiplan Commercial |
$234.79
|
| Rate for Payer: TriValley Medical Group Commercial |
$125.22
|
| Rate for Payer: TriValley Medical Group Senior |
$125.22
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$156.53
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$156.53
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$266.10
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$266.10
|
| Rate for Payer: Vantage Medical Group Senior |
$266.10
|
|
|
ELTROMBOPAG OLAMINE 25 MG TABLET [94579]
|
Facility
|
IP
|
$313.06
|
|
|
Service Code
|
NDC 0078068515
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$56.66 |
| Max. Negotiated Rate |
$234.79 |
| Rate for Payer: Adventist Health Commercial |
$62.61
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$201.61
|
| Rate for Payer: Cash Price |
$140.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$169.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$211.94
|
| Rate for Payer: Heritage Provider Network Senior |
$211.94
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$56.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$78.27
|
| Rate for Payer: Multiplan Commercial |
$234.79
|
|
|
ELTROMBOPAG OLAMINE 50 MG TABLET [94580]
|
Facility
|
IP
|
$566.53
|
|
|
Service Code
|
NDC 0078068615
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$102.54 |
| Max. Negotiated Rate |
$424.90 |
| Rate for Payer: Adventist Health Commercial |
$113.31
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$364.85
|
| Rate for Payer: Cash Price |
$254.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$305.93
|
| Rate for Payer: Heritage Provider Network Commercial |
$383.54
|
| Rate for Payer: Heritage Provider Network Senior |
$383.54
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$102.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$141.63
|
| Rate for Payer: Multiplan Commercial |
$424.90
|
|
|
ELTROMBOPAG OLAMINE 50 MG TABLET [94580]
|
Facility
|
OP
|
$566.53
|
|
|
Service Code
|
NDC 0078068615
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$102.54 |
| Max. Negotiated Rate |
$481.55 |
| Rate for Payer: Adventist Health Commercial |
$113.31
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$350.12
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$481.55
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$311.59
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$424.90
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$283.38
|
| Rate for Payer: Blue Shield of California Commercial |
$345.58
|
| Rate for Payer: Blue Shield of California EPN |
$276.47
|
| Rate for Payer: Cash Price |
$254.94
|
| Rate for Payer: Cigna of CA HMO/PPO |
$368.24
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$481.55
|
| Rate for Payer: Dignity Health Medi-Cal |
$481.55
|
| Rate for Payer: Dignity Health Medicare Advantage |
$481.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$362.58
|
| Rate for Payer: Heritage Provider Network Commercial |
$350.68
|
| Rate for Payer: Heritage Provider Network Senior |
$350.68
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$270.23
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$102.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$141.63
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$396.57
|
| Rate for Payer: Multiplan Commercial |
$424.90
|
| Rate for Payer: TriValley Medical Group Commercial |
$226.61
|
| Rate for Payer: TriValley Medical Group Senior |
$226.61
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$283.26
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$283.26
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$481.55
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$481.55
|
| Rate for Payer: Vantage Medical Group Senior |
$481.55
|
|
|
EMAPALUMAB-LZSG 5 MG/ML INTRAVENOUS SOLUTION [223872]
|
Facility
|
IP
|
$2,226.60
|
|
|
Service Code
|
HCPCS J9210
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$403.01 |
| Max. Negotiated Rate |
$1,669.95 |
| Rate for Payer: Adventist Health Commercial |
$445.32
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,433.93
|
| Rate for Payer: Cash Price |
$1,001.97
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,024.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,202.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,030.92
|
| Rate for Payer: Heritage Provider Network Senior |
$1,030.92
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$403.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$556.65
|
| Rate for Payer: Multiplan Commercial |
$1,669.95
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$804.47
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$737.23
|
|
|
EMAPALUMAB-LZSG 5 MG/ML INTRAVENOUS SOLUTION [223872]
|
Facility
|
OP
|
$2,226.60
|
|
|
Service Code
|
HCPCS J9210
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$344.45 |
| Max. Negotiated Rate |
$1,669.95 |
| Rate for Payer: Vantage Medical Group Senior |
$432.06
|
| Rate for Payer: Adventist Health Commercial |
$445.32
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,376.04
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$589.17
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$432.06
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$392.78
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$818.65
|
| 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 |
$1,001.97
|
| Rate for Payer: Cash Price |
$1,001.97
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,024.24
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$490.98
|
| Rate for Payer: Dignity Health Medi-Cal |
$432.06
|
| Rate for Payer: Dignity Health Medicare Advantage |
$432.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,425.02
|
| Rate for Payer: EPIC Health Plan Medicare |
$392.78
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,030.92
|
| Rate for Payer: Heritage Provider Network Senior |
$1,030.92
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$392.78
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$1,062.09
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$403.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$451.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$556.65
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$526.33
|
| Rate for Payer: Multiplan Commercial |
$1,669.95
|
| Rate for Payer: TriValley Medical Group Commercial |
$890.64
|
| Rate for Payer: TriValley Medical Group Senior |
$890.64
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$804.47
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$737.23
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$490.98
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$432.06
|
|
|
EMICIZUMAB-KXWH 105 MG/0.7 ML SUBCUTANEOUS SOLUTION [220371]
|
Facility
|
OP
|
$22,742.13
|
|
|
Service Code
|
HCPCS J7170
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$57.09 |
| Max. Negotiated Rate |
$17,056.60 |
| Rate for Payer: Adventist Health Commercial |
$4,548.43
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$14,054.64
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$72.54
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$63.83
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$63.83
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$120.20
|
| Rate for Payer: Blue Shield of California Commercial |
$57.09
|
| Rate for Payer: Blue Shield of California EPN |
$57.09
|
| Rate for Payer: Cash Price |
$10,233.96
|
| Rate for Payer: Cash Price |
$10,233.96
|
| Rate for Payer: Cigna of CA HMO/PPO |
$10,461.38
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$72.54
|
| Rate for Payer: Dignity Health Medi-Cal |
$63.83
|
| Rate for Payer: Dignity Health Medicare Advantage |
$63.83
|
| Rate for Payer: EPIC Health Plan Commercial |
$14,554.96
|
| Rate for Payer: EPIC Health Plan Medicare |
$58.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$10,529.61
|
| Rate for Payer: Heritage Provider Network Senior |
$10,529.61
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$58.03
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$10,848.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$4,116.33
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$66.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5,685.53
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$77.76
|
| Rate for Payer: Multiplan Commercial |
$17,056.60
|
| Rate for Payer: TriValley Medical Group Commercial |
$9,096.85
|
| Rate for Payer: TriValley Medical Group Senior |
$9,096.85
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$8,216.73
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$7,529.92
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$72.54
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$63.83
|
| Rate for Payer: Vantage Medical Group Senior |
$63.83
|
|
|
EMICIZUMAB-KXWH 105 MG/0.7 ML SUBCUTANEOUS SOLUTION [220371]
|
Facility
|
IP
|
$22,742.13
|
|
|
Service Code
|
HCPCS J7170
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4,116.33 |
| Max. Negotiated Rate |
$17,056.60 |
| Rate for Payer: Adventist Health Commercial |
$4,548.43
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$14,645.93
|
| Rate for Payer: Cash Price |
$10,233.96
|
| Rate for Payer: Cigna of CA HMO/PPO |
$10,461.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$12,280.75
|
| Rate for Payer: Heritage Provider Network Commercial |
$10,529.61
|
| Rate for Payer: Heritage Provider Network Senior |
$10,529.61
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$4,116.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5,685.53
|
| Rate for Payer: Multiplan Commercial |
$17,056.60
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$8,216.73
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$7,529.92
|
|
|
EMOLLIENT COMBINATION NO.10 TOPICAL EMULSION [42944]
|
Facility
|
OP
|
$0.58
|
|
|
Service Code
|
NDC 5898096012
|
| Hospital Charge Code |
901700029
|
|
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 Non-Gatekeeper |
$0.36
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$0.29
|
| Rate for Payer: Blue Shield of California Commercial |
$0.35
|
| Rate for Payer: Blue Shield of California EPN |
$0.28
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$0.28
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.41
|
| 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: United Healthcare All Other HMO/non HMO |
$0.29
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.29
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.49
|
| 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
|
IP
|
$0.58
|
|
|
Service Code
|
NDC 5898096012
|
| Hospital Charge Code |
901700029
|
|
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 |
$0.37
|
| 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 Foundation Hospitals 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.69 TOPICAL CREAM [196535]
|
Facility
|
OP
|
$0.03
|
|
|
Service Code
|
NDC 7214063378
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.02
|
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.02
|
| 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: United Healthcare All Other HMO/non HMO |
$0.02
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.03
|
| 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 |
901700029
|
|
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 Foundation Hospitals 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
|
$3.36
|
|
|
Service Code
|
NDC 9994080770
|
| Hospital Charge Code |
901700029
|
|
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 Non-Gatekeeper |
$2.08
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$1.68
|
| Rate for Payer: Blue Shield of California Commercial |
$2.05
|
| Rate for Payer: Blue Shield of California EPN |
$1.64
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$1.60
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.84
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$2.35
|
| 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: United Healthcare All Other HMO/non HMO |
$1.68
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.68
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.86
|
| 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
|
IP
|
$4.73
|
|
|
Service Code
|
NDC 9819300005
|
| Hospital Charge Code |
901700029
|
|
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 |
$3.05
|
| 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 Foundation Hospitals 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
|
$35.74
|
|
|
Service Code
|
NDC 9819300017
|
| Hospital Charge Code |
901700029
|
|
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 Non-Gatekeeper |
$22.09
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$17.88
|
| Rate for Payer: Blue Shield of California Commercial |
$21.80
|
| Rate for Payer: Blue Shield of California EPN |
$17.44
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$17.05
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$6.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.94
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$25.02
|
| 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: United Healthcare All Other HMO/non HMO |
$17.87
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$17.87
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$30.38
|
| 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
|
$3.36
|
|
|
Service Code
|
NDC 9994080770
|
| Hospital Charge Code |
901700029
|
|
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 |
$2.16
|
| 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 Foundation Hospitals 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
|
$5.11
|
|
|
Service Code
|
NDC 9940877002
|
| Hospital Charge Code |
901700029
|
|
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 |
$3.29
|
| 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 Foundation Hospitals 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
|
OP
|
$5.11
|
|
|
Service Code
|
NDC 9940877002
|
| Hospital Charge Code |
901700029
|
|
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 Non-Gatekeeper |
$3.16
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$2.56
|
| Rate for Payer: Blue Shield of California Commercial |
$3.12
|
| Rate for Payer: Blue Shield of California EPN |
$2.49
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$2.44
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.28
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$3.58
|
| 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: United Healthcare All Other HMO/non HMO |
$2.56
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.56
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.34
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.34
|
| Rate for Payer: Vantage Medical Group Senior |
$4.34
|
|
