|
ABEMACICLIB 150 MG TABLET [219900]
|
Facility
|
OP
|
$370.93
|
|
|
Service Code
|
NDC 0002533754
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$74.19 |
| Max. Negotiated Rate |
$315.29 |
| Rate for Payer: Adventist Health Commercial |
$74.19
|
| Rate for Payer: Aetna of CA HMO/PPO |
$243.29
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$315.29
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$204.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$278.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$238.03
|
| Rate for Payer: Cash Price |
$166.92
|
| Rate for Payer: Cigna of CA HMO |
$259.65
|
| Rate for Payer: Cigna of CA PPO |
$259.65
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$315.29
|
| Rate for Payer: Dignity Health Medi-Cal |
$315.29
|
| Rate for Payer: Dignity Health Medicare Advantage |
$315.29
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$259.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$148.37
|
| Rate for Payer: EPIC Health Plan Senior |
$148.37
|
| Rate for Payer: Galaxy Health WC |
$315.29
|
| Rate for Payer: Global Benefits Group Commercial |
$222.56
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$235.54
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$134.65
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$218.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$89.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$259.65
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$259.65
|
| Rate for Payer: Multiplan Commercial |
$296.74
|
| Rate for Payer: Networks By Design Commercial |
$241.10
|
| Rate for Payer: Prime Health Services Commercial |
$315.29
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$222.56
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$222.56
|
| Rate for Payer: United Healthcare All Other Commercial |
$185.47
|
| Rate for Payer: United Healthcare All Other HMO |
$185.47
|
| Rate for Payer: United Healthcare HMO Rider |
$185.47
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$185.47
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$315.29
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$315.29
|
| Rate for Payer: Vantage Medical Group Senior |
$315.29
|
|
|
ABEMACICLIB 150 MG TABLET [219900]
|
Facility
|
IP
|
$370.93
|
|
|
Service Code
|
NDC 0002533754
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$74.19 |
| Max. Negotiated Rate |
$315.29 |
| Rate for Payer: Adventist Health Commercial |
$74.19
|
| Rate for Payer: Blue Shield of California Commercial |
$188.06
|
| Rate for Payer: Blue Shield of California Commercial |
$285.25
|
| Rate for Payer: Cash Price |
$166.92
|
| Rate for Payer: Cigna of CA HMO |
$259.65
|
| Rate for Payer: Cigna of CA PPO |
$259.65
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$259.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$148.37
|
| Rate for Payer: EPIC Health Plan Senior |
$148.37
|
| Rate for Payer: Galaxy Health WC |
$315.29
|
| Rate for Payer: Global Benefits Group Commercial |
$222.56
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$235.54
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$218.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$89.02
|
| Rate for Payer: Multiplan Commercial |
$296.74
|
| Rate for Payer: Networks By Design Commercial |
$241.10
|
| Rate for Payer: Prime Health Services Commercial |
$315.29
|
|
|
ABEMACICLIB 200 MG TABLET [219899]
|
Facility
|
IP
|
$370.93
|
|
|
Service Code
|
NDC 0002621654
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$74.19 |
| Max. Negotiated Rate |
$315.29 |
| Rate for Payer: Adventist Health Commercial |
$74.19
|
| Rate for Payer: Blue Shield of California Commercial |
$188.06
|
| Rate for Payer: Blue Shield of California Commercial |
$285.25
|
| Rate for Payer: Cash Price |
$166.92
|
| Rate for Payer: Cigna of CA HMO |
$259.65
|
| Rate for Payer: Cigna of CA PPO |
$259.65
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$259.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$148.37
|
| Rate for Payer: EPIC Health Plan Senior |
$148.37
|
| Rate for Payer: Galaxy Health WC |
$315.29
|
| Rate for Payer: Global Benefits Group Commercial |
$222.56
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$235.54
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$218.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$89.02
|
| Rate for Payer: Multiplan Commercial |
$296.74
|
| Rate for Payer: Networks By Design Commercial |
$241.10
|
| Rate for Payer: Prime Health Services Commercial |
$315.29
|
|
|
ABEMACICLIB 200 MG TABLET [219899]
|
Facility
|
OP
|
$370.93
|
|
|
Service Code
|
NDC 0002621654
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$74.19 |
| Max. Negotiated Rate |
$315.29 |
| Rate for Payer: Adventist Health Commercial |
$74.19
|
| Rate for Payer: Aetna of CA HMO/PPO |
$243.29
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$315.29
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$204.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$278.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$238.03
|
| Rate for Payer: Cash Price |
$166.92
|
| Rate for Payer: Cigna of CA HMO |
$259.65
|
| Rate for Payer: Cigna of CA PPO |
$259.65
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$315.29
|
| Rate for Payer: Dignity Health Medi-Cal |
$315.29
|
| Rate for Payer: Dignity Health Medicare Advantage |
$315.29
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$259.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$148.37
|
| Rate for Payer: EPIC Health Plan Senior |
$148.37
|
| Rate for Payer: Galaxy Health WC |
$315.29
|
| Rate for Payer: Global Benefits Group Commercial |
$222.56
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$235.54
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$134.65
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$218.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$89.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$259.65
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$259.65
|
| Rate for Payer: Multiplan Commercial |
$296.74
|
| Rate for Payer: Networks By Design Commercial |
$241.10
|
| Rate for Payer: Prime Health Services Commercial |
$315.29
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$222.56
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$222.56
|
| Rate for Payer: United Healthcare All Other Commercial |
$185.47
|
| Rate for Payer: United Healthcare All Other HMO |
$185.47
|
| Rate for Payer: United Healthcare HMO Rider |
$185.47
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$185.47
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$315.29
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$315.29
|
| Rate for Payer: Vantage Medical Group Senior |
$315.29
|
|
|
ABEMACICLIB 50 MG TABLET [219902]
|
Facility
|
OP
|
$370.93
|
|
|
Service Code
|
NDC 0002448354
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$74.19 |
| Max. Negotiated Rate |
$315.29 |
| Rate for Payer: Adventist Health Commercial |
$74.19
|
| Rate for Payer: Aetna of CA HMO/PPO |
$243.29
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$315.29
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$204.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$278.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$238.03
|
| Rate for Payer: Cash Price |
$166.92
|
| Rate for Payer: Cigna of CA HMO |
$259.65
|
| Rate for Payer: Cigna of CA PPO |
$259.65
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$315.29
|
| Rate for Payer: Dignity Health Medi-Cal |
$315.29
|
| Rate for Payer: Dignity Health Medicare Advantage |
$315.29
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$259.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$148.37
|
| Rate for Payer: EPIC Health Plan Senior |
$148.37
|
| Rate for Payer: Galaxy Health WC |
$315.29
|
| Rate for Payer: Global Benefits Group Commercial |
$222.56
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$235.54
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$134.65
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$218.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$89.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$259.65
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$259.65
|
| Rate for Payer: Multiplan Commercial |
$296.74
|
| Rate for Payer: Networks By Design Commercial |
$241.10
|
| Rate for Payer: Prime Health Services Commercial |
$315.29
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$222.56
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$222.56
|
| Rate for Payer: United Healthcare All Other Commercial |
$185.47
|
| Rate for Payer: United Healthcare All Other HMO |
$185.47
|
| Rate for Payer: United Healthcare HMO Rider |
$185.47
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$185.47
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$315.29
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$315.29
|
| Rate for Payer: Vantage Medical Group Senior |
$315.29
|
|
|
ABEMACICLIB 50 MG TABLET [219902]
|
Facility
|
IP
|
$370.93
|
|
|
Service Code
|
NDC 0002448354
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$74.19 |
| Max. Negotiated Rate |
$315.29 |
| Rate for Payer: Adventist Health Commercial |
$74.19
|
| Rate for Payer: Blue Shield of California Commercial |
$188.06
|
| Rate for Payer: Blue Shield of California Commercial |
$285.25
|
| Rate for Payer: Cash Price |
$166.92
|
| Rate for Payer: Cigna of CA HMO |
$259.65
|
| Rate for Payer: Cigna of CA PPO |
$259.65
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$259.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$148.37
|
| Rate for Payer: EPIC Health Plan Senior |
$148.37
|
| Rate for Payer: Galaxy Health WC |
$315.29
|
| Rate for Payer: Global Benefits Group Commercial |
$222.56
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$235.54
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$218.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$89.02
|
| Rate for Payer: Multiplan Commercial |
$296.74
|
| Rate for Payer: Networks By Design Commercial |
$241.10
|
| Rate for Payer: Prime Health Services Commercial |
$315.29
|
|
|
ABIRATERONE 250 MG TABLET [109776]
|
Facility
|
IP
|
$125.67
|
|
|
Service Code
|
NDC 5789415012
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$25.13 |
| Max. Negotiated Rate |
$106.82 |
| Rate for Payer: Adventist Health Commercial |
$25.13
|
| Rate for Payer: Blue Shield of California Commercial |
$63.71
|
| Rate for Payer: Blue Shield of California Commercial |
$96.64
|
| Rate for Payer: Cash Price |
$56.55
|
| Rate for Payer: Cigna of CA HMO |
$87.97
|
| Rate for Payer: Cigna of CA PPO |
$87.97
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$87.97
|
| Rate for Payer: EPIC Health Plan Commercial |
$50.27
|
| Rate for Payer: EPIC Health Plan Senior |
$50.27
|
| Rate for Payer: Galaxy Health WC |
$106.82
|
| Rate for Payer: Global Benefits Group Commercial |
$75.40
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$79.80
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$74.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$30.16
|
| Rate for Payer: Multiplan Commercial |
$100.54
|
| Rate for Payer: Networks By Design Commercial |
$81.69
|
| Rate for Payer: Prime Health Services Commercial |
$106.82
|
|
|
ABIRATERONE 250 MG TABLET [109776]
|
Facility
|
OP
|
$125.67
|
|
|
Service Code
|
NDC 5789415012
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$25.13 |
| Max. Negotiated Rate |
$106.82 |
| Rate for Payer: Adventist Health Commercial |
$25.13
|
| Rate for Payer: Aetna of CA HMO/PPO |
$82.43
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$106.82
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$69.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$94.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$80.64
|
| Rate for Payer: Cash Price |
$56.55
|
| Rate for Payer: Cigna of CA HMO |
$87.97
|
| Rate for Payer: Cigna of CA PPO |
$87.97
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$106.82
|
| Rate for Payer: Dignity Health Medi-Cal |
$106.82
|
| Rate for Payer: Dignity Health Medicare Advantage |
$106.82
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$87.97
|
| Rate for Payer: EPIC Health Plan Commercial |
$50.27
|
| Rate for Payer: EPIC Health Plan Senior |
$50.27
|
| Rate for Payer: Galaxy Health WC |
$106.82
|
| Rate for Payer: Global Benefits Group Commercial |
$75.40
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$79.80
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$45.62
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$74.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$30.16
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$87.97
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$87.97
|
| Rate for Payer: Multiplan Commercial |
$100.54
|
| Rate for Payer: Networks By Design Commercial |
$81.69
|
| Rate for Payer: Prime Health Services Commercial |
$106.82
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$75.40
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$75.40
|
| Rate for Payer: United Healthcare All Other Commercial |
$62.84
|
| Rate for Payer: United Healthcare All Other HMO |
$62.84
|
| Rate for Payer: United Healthcare HMO Rider |
$62.84
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$62.84
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$106.82
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$106.82
|
| Rate for Payer: Vantage Medical Group Senior |
$106.82
|
|
|
ABOBOTULINUMTOXINA 300 UNIT INTRAMUSCULAR SOLUTION [106761]
|
Facility
|
OP
|
$634.20
|
|
|
Service Code
|
HCPCS J0586
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.95 |
| Max. Negotiated Rate |
$539.07 |
| Rate for Payer: Galaxy Health WC |
$539.07
|
| Rate for Payer: Adventist Health Commercial |
$126.84
|
| Rate for Payer: Aetna of CA HMO/PPO |
$56.85
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$11.19
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$9.85
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9.85
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$18.22
|
| Rate for Payer: Blue Shield of California Commercial |
$10.31
|
| Rate for Payer: Cash Price |
$285.39
|
| Rate for Payer: Cash Price |
$285.39
|
| Rate for Payer: Cigna of CA HMO |
$443.94
|
| Rate for Payer: Cigna of CA PPO |
$443.94
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.19
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.85
|
| Rate for Payer: Dignity Health Medicare Advantage |
$9.85
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$443.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.77
|
| Rate for Payer: EPIC Health Plan Senior |
$9.85
|
| Rate for Payer: Global Benefits Group Commercial |
$380.52
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$14.68
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$8.95
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$8.95
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$402.72
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$25.19
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$12.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$152.21
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$11.28
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$11.99
|
| Rate for Payer: Multiplan Commercial |
$507.36
|
| Rate for Payer: Networks By Design Commercial |
$317.10
|
| Rate for Payer: Prime Health Services Commercial |
$539.07
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$380.52
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$380.52
|
| Rate for Payer: United Healthcare All Other Commercial |
$238.02
|
| Rate for Payer: United Healthcare All Other HMO |
$231.67
|
| Rate for Payer: United Healthcare HMO Rider |
$226.66
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$207.70
|
| Rate for Payer: Upland Medical Group Pediatric |
$8.95
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$11.19
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.85
|
| Rate for Payer: Vantage Medical Group Senior |
$9.85
|
|
|
ABOBOTULINUMTOXINA 300 UNIT INTRAMUSCULAR SOLUTION [106761]
|
Facility
|
IP
|
$634.20
|
|
|
Service Code
|
HCPCS J0586
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$126.84 |
| Max. Negotiated Rate |
$539.07 |
| Rate for Payer: Adventist Health Commercial |
$126.84
|
| Rate for Payer: Blue Shield of California Commercial |
$321.54
|
| Rate for Payer: Blue Shield of California Commercial |
$487.70
|
| Rate for Payer: Cash Price |
$285.39
|
| Rate for Payer: Cigna of CA HMO |
$443.94
|
| Rate for Payer: Cigna of CA PPO |
$443.94
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$443.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$253.68
|
| Rate for Payer: EPIC Health Plan Senior |
$253.68
|
| Rate for Payer: Galaxy Health WC |
$539.07
|
| Rate for Payer: Global Benefits Group Commercial |
$380.52
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$402.72
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$374.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$152.21
|
| Rate for Payer: Multiplan Commercial |
$507.36
|
| Rate for Payer: Networks By Design Commercial |
$317.10
|
| Rate for Payer: Prime Health Services Commercial |
$539.07
|
| Rate for Payer: United Healthcare All Other Commercial |
$238.02
|
| Rate for Payer: United Healthcare All Other HMO |
$231.67
|
| Rate for Payer: United Healthcare HMO Rider |
$226.66
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$207.70
|
|
|
ABOBOTULINUMTOXINA 500 UNIT INTRAMUSCULAR SOLUTION [99465]
|
Facility
|
OP
|
$1,056.60
|
|
|
Service Code
|
HCPCS J0586
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.95 |
| Max. Negotiated Rate |
$898.11 |
| Rate for Payer: Adventist Health Commercial |
$211.32
|
| Rate for Payer: Aetna of CA HMO/PPO |
$56.85
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$11.19
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$9.85
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9.85
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$18.22
|
| Rate for Payer: Blue Shield of California Commercial |
$10.31
|
| Rate for Payer: Cash Price |
$475.47
|
| Rate for Payer: Cash Price |
$475.47
|
| Rate for Payer: Cigna of CA HMO |
$739.62
|
| Rate for Payer: Cigna of CA PPO |
$739.62
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.19
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.85
|
| Rate for Payer: Dignity Health Medicare Advantage |
$9.85
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$739.62
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.77
|
| Rate for Payer: EPIC Health Plan Senior |
$9.85
|
| Rate for Payer: Galaxy Health WC |
$898.11
|
| Rate for Payer: Global Benefits Group Commercial |
$633.96
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$14.68
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$8.95
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$8.95
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$670.94
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$25.19
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$12.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$253.58
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$11.28
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$11.99
|
| Rate for Payer: Multiplan Commercial |
$845.28
|
| Rate for Payer: Networks By Design Commercial |
$528.30
|
| Rate for Payer: Prime Health Services Commercial |
$898.11
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$633.96
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$633.96
|
| Rate for Payer: United Healthcare All Other Commercial |
$396.54
|
| Rate for Payer: United Healthcare All Other HMO |
$385.98
|
| Rate for Payer: United Healthcare HMO Rider |
$377.63
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$346.04
|
| Rate for Payer: Upland Medical Group Pediatric |
$8.95
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$11.19
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.85
|
| Rate for Payer: Vantage Medical Group Senior |
$9.85
|
|
|
ABOBOTULINUMTOXINA 500 UNIT INTRAMUSCULAR SOLUTION [99465]
|
Facility
|
IP
|
$1,056.60
|
|
|
Service Code
|
HCPCS J0586
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$211.32 |
| Max. Negotiated Rate |
$898.11 |
| Rate for Payer: Adventist Health Commercial |
$211.32
|
| Rate for Payer: Blue Shield of California Commercial |
$535.70
|
| Rate for Payer: Blue Shield of California Commercial |
$812.53
|
| Rate for Payer: Cash Price |
$475.47
|
| Rate for Payer: Cigna of CA HMO |
$739.62
|
| Rate for Payer: Cigna of CA PPO |
$739.62
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$739.62
|
| Rate for Payer: EPIC Health Plan Commercial |
$422.64
|
| Rate for Payer: EPIC Health Plan Senior |
$422.64
|
| Rate for Payer: Galaxy Health WC |
$898.11
|
| Rate for Payer: Global Benefits Group Commercial |
$633.96
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$670.94
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$623.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$253.58
|
| Rate for Payer: Multiplan Commercial |
$845.28
|
| Rate for Payer: Networks By Design Commercial |
$528.30
|
| Rate for Payer: Prime Health Services Commercial |
$898.11
|
| Rate for Payer: United Healthcare All Other Commercial |
$396.54
|
| Rate for Payer: United Healthcare All Other HMO |
$385.98
|
| Rate for Payer: United Healthcare HMO Rider |
$377.63
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$346.04
|
|
|
ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY
|
Facility
|
IP
|
$12,484.09
|
|
|
Service Code
|
APR-DRG 5431
|
| Min. Negotiated Rate |
$6,888.95 |
| Max. Negotiated Rate |
$12,484.09 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$6,888.95
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$8,625.37
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$12,484.09
|
|
|
ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY
|
Facility
|
IP
|
$97,042.36
|
|
|
Service Code
|
MSDRG 770
|
| Min. Negotiated Rate |
$7,611.00 |
| Max. Negotiated Rate |
$97,042.36 |
| Rate for Payer: Aetna of CA HMO/PPO |
$30,397.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$97,042.36
|
| Rate for Payer: EPIC Health Plan Senior |
$64,694.90
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$58,813.55
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$82,338.97
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$78,810.16
|
| Rate for Payer: United Healthcare All Other Commercial |
$12,844.00
|
| Rate for Payer: United Healthcare All Other HMO |
$10,823.00
|
| Rate for Payer: United Healthcare HMO Rider |
$8,307.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$7,611.00
|
|
|
ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY
|
Facility
|
IP
|
$16,431.66
|
|
|
Service Code
|
APR-DRG 5432
|
| Min. Negotiated Rate |
$9,067.29 |
| Max. Negotiated Rate |
$16,431.66 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$9,067.29
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$11,352.78
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$16,431.66
|
|
|
ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY
|
Facility
|
IP
|
$26,597.23
|
|
|
Service Code
|
APR-DRG 5433
|
| Min. Negotiated Rate |
$14,676.84 |
| Max. Negotiated Rate |
$26,597.23 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$14,676.84
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$18,376.27
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$26,597.23
|
|
|
ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY
|
Facility
|
IP
|
$48,592.09
|
|
|
Service Code
|
APR-DRG 5434
|
| Min. Negotiated Rate |
$26,814.00 |
| Max. Negotiated Rate |
$48,592.09 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$26,814.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$33,572.71
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$48,592.09
|
|
|
ABORTION WITHOUT D&C
|
Facility
|
IP
|
$94,178.35
|
|
|
Service Code
|
MSDRG 779
|
| Min. Negotiated Rate |
$6,823.00 |
| Max. Negotiated Rate |
$94,178.35 |
| Rate for Payer: Aetna of CA HMO/PPO |
$21,618.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$94,178.35
|
| Rate for Payer: EPIC Health Plan Senior |
$62,785.57
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$57,077.79
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$79,908.91
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$76,484.24
|
| Rate for Payer: United Healthcare All Other Commercial |
$10,506.00
|
| Rate for Payer: United Healthcare All Other HMO |
$8,385.00
|
| Rate for Payer: United Healthcare HMO Rider |
$7,448.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6,823.00
|
|
|
ABORTION WITHOUT D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY
|
Facility
|
IP
|
$10,300.26
|
|
|
Service Code
|
APR-DRG 5642
|
| Min. Negotiated Rate |
$5,683.87 |
| Max. Negotiated Rate |
$10,300.26 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$5,683.87
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$7,116.55
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$10,300.26
|
|
|
ABORTION WITHOUT D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY
|
Facility
|
IP
|
$39,573.68
|
|
|
Service Code
|
APR-DRG 5644
|
| Min. Negotiated Rate |
$21,837.48 |
| Max. Negotiated Rate |
$39,573.68 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$21,837.48
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$27,341.82
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$39,573.68
|
|
|
ABORTION WITHOUT D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY
|
Facility
|
IP
|
$8,039.46
|
|
|
Service Code
|
APR-DRG 5641
|
| Min. Negotiated Rate |
$4,436.32 |
| Max. Negotiated Rate |
$8,039.46 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$4,436.32
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$5,554.54
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$8,039.46
|
|
|
ABORTION WITHOUT D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY
|
Facility
|
IP
|
$17,608.55
|
|
|
Service Code
|
APR-DRG 5643
|
| Min. Negotiated Rate |
$9,716.72 |
| Max. Negotiated Rate |
$17,608.55 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$9,716.72
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$12,165.91
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$17,608.55
|
|
|
ACAMPROSATE 333 MG TABLET,DELAYED RELEASE [39720]
|
Facility
|
IP
|
$0.99
|
|
|
Service Code
|
NDC 6945235325
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.84 |
| Rate for Payer: Adventist Health Commercial |
$0.20
|
| Rate for Payer: Blue Shield of California Commercial |
$0.50
|
| Rate for Payer: Blue Shield of California Commercial |
$0.76
|
| Rate for Payer: Cash Price |
$0.45
|
| Rate for Payer: Cigna of CA HMO |
$0.69
|
| Rate for Payer: Cigna of CA PPO |
$0.69
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.69
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.40
|
| Rate for Payer: EPIC Health Plan Senior |
$0.40
|
| Rate for Payer: Galaxy Health WC |
$0.84
|
| Rate for Payer: Global Benefits Group Commercial |
$0.59
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.63
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
| Rate for Payer: Multiplan Commercial |
$0.79
|
| Rate for Payer: Networks By Design Commercial |
$0.64
|
| Rate for Payer: Prime Health Services Commercial |
$0.84
|
|
|
ACAMPROSATE 333 MG TABLET,DELAYED RELEASE [39720]
|
Facility
|
OP
|
$1.32
|
|
|
Service Code
|
NDC 6846243518
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$1.12 |
| Rate for Payer: Adventist Health Commercial |
$0.26
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.87
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.12
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.73
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.99
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.85
|
| Rate for Payer: Cash Price |
$0.59
|
| Rate for Payer: Cigna of CA HMO |
$0.92
|
| Rate for Payer: Cigna of CA PPO |
$0.92
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.12
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.12
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.53
|
| Rate for Payer: EPIC Health Plan Senior |
$0.53
|
| Rate for Payer: Galaxy Health WC |
$1.12
|
| Rate for Payer: Global Benefits Group Commercial |
$0.79
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.84
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.48
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.92
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.92
|
| Rate for Payer: Multiplan Commercial |
$1.06
|
| Rate for Payer: Networks By Design Commercial |
$0.86
|
| Rate for Payer: Prime Health Services Commercial |
$1.12
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.79
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.79
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.66
|
| Rate for Payer: United Healthcare All Other HMO |
$0.66
|
| Rate for Payer: United Healthcare HMO Rider |
$0.66
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.66
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.12
|
| Rate for Payer: Vantage Medical Group Senior |
$1.12
|
|
|
ACAMPROSATE 333 MG TABLET,DELAYED RELEASE [39720]
|
Facility
|
OP
|
$1.08
|
|
|
Service Code
|
NDC 0378633380
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$0.92 |
| Rate for Payer: Adventist Health Commercial |
$0.22
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.71
|
| 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 |
$0.69
|
| Rate for Payer: Cash Price |
$0.49
|
| Rate for Payer: Cigna of CA HMO |
$0.76
|
| Rate for Payer: Cigna of CA PPO |
$0.76
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.43
|
| Rate for Payer: EPIC Health Plan Senior |
$0.43
|
| Rate for Payer: Galaxy Health WC |
$0.92
|
| Rate for Payer: Global Benefits Group Commercial |
$0.65
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.69
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.39
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.26
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.76
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.76
|
| Rate for Payer: Multiplan Commercial |
$0.86
|
| Rate for Payer: Networks By Design Commercial |
$0.70
|
| Rate for Payer: Prime Health Services Commercial |
$0.92
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.65
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.65
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.54
|
| Rate for Payer: United Healthcare All Other HMO |
$0.54
|
| Rate for Payer: United Healthcare HMO Rider |
$0.54
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$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
|
|
