|
GLYCOPYRROLATE 2 MG TABLET [10131]
|
Facility
|
OP
|
$1.78
|
|
|
Service Code
|
NDC 5511164901
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$1.51 |
| Rate for Payer: Adventist Health Commercial |
$0.36
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.17
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.51
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.98
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.33
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.14
|
| Rate for Payer: Cash Price |
$0.80
|
| Rate for Payer: Cigna of CA HMO |
$1.25
|
| Rate for Payer: Cigna of CA PPO |
$1.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.51
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.51
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.51
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.71
|
| Rate for Payer: EPIC Health Plan Senior |
$0.71
|
| Rate for Payer: Galaxy Health WC |
$1.51
|
| Rate for Payer: Global Benefits Group Commercial |
$1.07
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.13
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.65
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.43
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.25
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.25
|
| Rate for Payer: Multiplan Commercial |
$1.42
|
| Rate for Payer: Networks By Design Commercial |
$1.16
|
| Rate for Payer: Prime Health Services Commercial |
$1.51
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.07
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.07
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.89
|
| Rate for Payer: United Healthcare All Other HMO |
$0.89
|
| Rate for Payer: United Healthcare HMO Rider |
$0.89
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.89
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.51
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.51
|
| Rate for Payer: Vantage Medical Group Senior |
$1.51
|
|
|
GLYCOPYRROLATE 2 MG TABLET [10131]
|
Facility
|
OP
|
$0.26
|
|
|
Service Code
|
NDC 2315560701
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.22 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.17
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.22
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.17
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cigna of CA HMO |
$0.18
|
| Rate for Payer: Cigna of CA PPO |
$0.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.22
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.22
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: EPIC Health Plan Senior |
$0.10
|
| Rate for Payer: Galaxy Health WC |
$0.22
|
| Rate for Payer: Global Benefits Group Commercial |
$0.16
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.17
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.09
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.18
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.21
|
| Rate for Payer: Networks By Design Commercial |
$0.17
|
| Rate for Payer: Prime Health Services Commercial |
$0.22
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.16
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.16
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.13
|
| Rate for Payer: United Healthcare All Other HMO |
$0.13
|
| Rate for Payer: United Healthcare HMO Rider |
$0.13
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.13
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.22
|
| Rate for Payer: Vantage Medical Group Senior |
$0.22
|
|
|
GLYCOPYRROLATE 2 MG TABLET [10131]
|
Facility
|
OP
|
$0.93
|
|
|
Service Code
|
NDC 6498027301
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.79 |
| Rate for Payer: Adventist Health Commercial |
$0.19
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.61
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.79
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.51
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.70
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.60
|
| Rate for Payer: Cash Price |
$0.42
|
| Rate for Payer: Cigna of CA HMO |
$0.65
|
| Rate for Payer: Cigna of CA PPO |
$0.65
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.79
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.79
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.79
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.37
|
| Rate for Payer: EPIC Health Plan Senior |
$0.37
|
| Rate for Payer: Galaxy Health WC |
$0.79
|
| Rate for Payer: Global Benefits Group Commercial |
$0.56
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.59
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.34
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.22
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.65
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.65
|
| Rate for Payer: Multiplan Commercial |
$0.74
|
| Rate for Payer: Networks By Design Commercial |
$0.60
|
| Rate for Payer: Prime Health Services Commercial |
$0.79
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.56
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.56
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.47
|
| Rate for Payer: United Healthcare All Other HMO |
$0.47
|
| Rate for Payer: United Healthcare HMO Rider |
$0.47
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.47
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.79
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.79
|
| Rate for Payer: Vantage Medical Group Senior |
$0.79
|
|
|
GLYCOPYRROLATE 2 MG TABLET [10131]
|
Facility
|
OP
|
$0.26
|
|
|
Service Code
|
NDC 1310701501
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.22 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.17
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.22
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.17
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cigna of CA HMO |
$0.18
|
| Rate for Payer: Cigna of CA PPO |
$0.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.22
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.22
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: EPIC Health Plan Senior |
$0.10
|
| Rate for Payer: Galaxy Health WC |
$0.22
|
| Rate for Payer: Global Benefits Group Commercial |
$0.16
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.17
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.09
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.18
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.21
|
| Rate for Payer: Networks By Design Commercial |
$0.17
|
| Rate for Payer: Prime Health Services Commercial |
$0.22
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.16
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.16
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.13
|
| Rate for Payer: United Healthcare All Other HMO |
$0.13
|
| Rate for Payer: United Healthcare HMO Rider |
$0.13
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.13
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.22
|
| Rate for Payer: Vantage Medical Group Senior |
$0.22
|
|
|
GLYCOPYRROLATE 2 MG TABLET [10131]
|
Facility
|
IP
|
$0.93
|
|
|
Service Code
|
NDC 4988406601
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.79 |
| Rate for Payer: Adventist Health Commercial |
$0.19
|
| Rate for Payer: Blue Shield of California Commercial |
$0.47
|
| Rate for Payer: Blue Shield of California Commercial |
$0.72
|
| Rate for Payer: Cash Price |
$0.42
|
| Rate for Payer: Cigna of CA HMO |
$0.65
|
| Rate for Payer: Cigna of CA PPO |
$0.65
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.37
|
| Rate for Payer: EPIC Health Plan Senior |
$0.37
|
| Rate for Payer: Galaxy Health WC |
$0.79
|
| Rate for Payer: Global Benefits Group Commercial |
$0.56
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.59
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.22
|
| Rate for Payer: Multiplan Commercial |
$0.74
|
| Rate for Payer: Networks By Design Commercial |
$0.60
|
| Rate for Payer: Prime Health Services Commercial |
$0.79
|
|
|
GLYCOPYRROLATE ORAL SOLUTION (IV FORM) 0.2 MG/ML [4080432]
|
Facility
|
IP
|
$2.63
|
|
|
Service Code
|
NDC 9994080432
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.53 |
| Max. Negotiated Rate |
$2.24 |
| Rate for Payer: Adventist Health Commercial |
$0.53
|
| Rate for Payer: Blue Shield of California Commercial |
$1.33
|
| Rate for Payer: Blue Shield of California Commercial |
$2.02
|
| Rate for Payer: Cash Price |
$1.18
|
| Rate for Payer: Cigna of CA HMO |
$1.84
|
| Rate for Payer: Cigna of CA PPO |
$1.84
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.05
|
| Rate for Payer: EPIC Health Plan Senior |
$1.05
|
| Rate for Payer: Galaxy Health WC |
$2.24
|
| Rate for Payer: Global Benefits Group Commercial |
$1.58
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.67
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.63
|
| Rate for Payer: Multiplan Commercial |
$2.10
|
| Rate for Payer: Networks By Design Commercial |
$1.71
|
| Rate for Payer: Prime Health Services Commercial |
$2.24
|
|
|
GLYCOPYRROLATE ORAL SOLUTION (IV FORM) 0.2 MG/ML [4080432]
|
Facility
|
OP
|
$2.63
|
|
|
Service Code
|
NDC 9994080432
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.53 |
| Max. Negotiated Rate |
$2.24 |
| Rate for Payer: Adventist Health Commercial |
$0.53
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.73
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.24
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.45
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.97
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.69
|
| Rate for Payer: Cash Price |
$1.18
|
| Rate for Payer: Cigna of CA HMO |
$1.84
|
| Rate for Payer: Cigna of CA PPO |
$1.84
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.24
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.24
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.24
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.05
|
| Rate for Payer: EPIC Health Plan Senior |
$1.05
|
| Rate for Payer: Galaxy Health WC |
$2.24
|
| Rate for Payer: Global Benefits Group Commercial |
$1.58
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.67
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.95
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.63
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.84
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.84
|
| Rate for Payer: Multiplan Commercial |
$2.10
|
| Rate for Payer: Networks By Design Commercial |
$1.71
|
| Rate for Payer: Prime Health Services Commercial |
$2.24
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.58
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.58
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.31
|
| Rate for Payer: United Healthcare All Other HMO |
$1.31
|
| Rate for Payer: United Healthcare HMO Rider |
$1.31
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.31
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.24
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.24
|
| Rate for Payer: Vantage Medical Group Senior |
$2.24
|
|
|
GOLIMUMAB 12.5 MG/ML INTRAVENOUS SOLUTION [203118]
|
Facility
|
IP
|
$599.76
|
|
|
Service Code
|
HCPCS J1602
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$119.95 |
| Max. Negotiated Rate |
$509.80 |
| Rate for Payer: Adventist Health Commercial |
$119.95
|
| Rate for Payer: Blue Shield of California Commercial |
$304.08
|
| Rate for Payer: Blue Shield of California Commercial |
$461.22
|
| Rate for Payer: Cash Price |
$269.89
|
| Rate for Payer: Cigna of CA HMO |
$419.83
|
| Rate for Payer: Cigna of CA PPO |
$419.83
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$419.83
|
| Rate for Payer: EPIC Health Plan Commercial |
$239.90
|
| Rate for Payer: EPIC Health Plan Senior |
$239.90
|
| Rate for Payer: Galaxy Health WC |
$509.80
|
| Rate for Payer: Global Benefits Group Commercial |
$359.86
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$380.85
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$353.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$143.94
|
| Rate for Payer: Multiplan Commercial |
$479.81
|
| Rate for Payer: Networks By Design Commercial |
$299.88
|
| Rate for Payer: Prime Health Services Commercial |
$509.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$225.09
|
| Rate for Payer: United Healthcare All Other HMO |
$219.09
|
| Rate for Payer: United Healthcare HMO Rider |
$214.35
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$196.42
|
|
|
GOLIMUMAB 12.5 MG/ML INTRAVENOUS SOLUTION [203118]
|
Facility
|
OP
|
$599.76
|
|
|
Service Code
|
HCPCS J1602
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.04 |
| Max. Negotiated Rate |
$509.80 |
| Rate for Payer: Adventist Health Commercial |
$119.95
|
| Rate for Payer: Aetna of CA HMO/PPO |
$67.75
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$13.80
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$12.14
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$12.14
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$58.79
|
| Rate for Payer: Blue Shield of California Commercial |
$47.98
|
| Rate for Payer: Cash Price |
$269.89
|
| Rate for Payer: Cash Price |
$269.89
|
| Rate for Payer: Cigna of CA HMO |
$419.83
|
| Rate for Payer: Cigna of CA PPO |
$419.83
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$13.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$12.14
|
| Rate for Payer: Dignity Health Medicare Advantage |
$12.14
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$419.83
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.22
|
| Rate for Payer: EPIC Health Plan Senior |
$12.14
|
| Rate for Payer: Galaxy Health WC |
$509.80
|
| Rate for Payer: Global Benefits Group Commercial |
$359.86
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$18.11
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$11.04
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$11.04
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$380.85
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$22.10
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$15.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$143.94
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$13.91
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$14.79
|
| Rate for Payer: Multiplan Commercial |
$479.81
|
| Rate for Payer: Networks By Design Commercial |
$299.88
|
| Rate for Payer: Prime Health Services Commercial |
$509.80
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$359.86
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$359.86
|
| Rate for Payer: United Healthcare All Other Commercial |
$225.09
|
| Rate for Payer: United Healthcare All Other HMO |
$219.09
|
| Rate for Payer: United Healthcare HMO Rider |
$214.35
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$196.42
|
| Rate for Payer: Upland Medical Group Pediatric |
$11.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$13.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$12.14
|
| Rate for Payer: Vantage Medical Group Senior |
$12.14
|
|
|
GOLODIRSEN 50 MG/ML INTRAVENOUS SOLUTION [226694]
|
Facility
|
OP
|
$960.00
|
|
|
Service Code
|
HCPCS J1429
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$192.00 |
| Max. Negotiated Rate |
$992.37 |
| Rate for Payer: Adventist Health Commercial |
$192.00
|
| Rate for Payer: Aetna of CA HMO/PPO |
$992.37
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$816.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$528.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$720.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$408.78
|
| Rate for Payer: Blue Shield of California Commercial |
$192.00
|
| Rate for Payer: Cash Price |
$432.00
|
| Rate for Payer: Cash Price |
$432.00
|
| Rate for Payer: Cigna of CA HMO |
$672.00
|
| Rate for Payer: Cigna of CA PPO |
$672.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$816.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$816.00
|
| Rate for Payer: Dignity Health Medicare Advantage |
$816.00
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$672.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$384.00
|
| Rate for Payer: EPIC Health Plan Senior |
$384.00
|
| Rate for Payer: Galaxy Health WC |
$816.00
|
| Rate for Payer: Global Benefits Group Commercial |
$576.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$276.29
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$609.60
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$312.47
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$566.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$230.40
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$672.00
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$672.00
|
| Rate for Payer: Multiplan Commercial |
$768.00
|
| Rate for Payer: Networks By Design Commercial |
$480.00
|
| Rate for Payer: Prime Health Services Commercial |
$816.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$576.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$576.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$360.29
|
| Rate for Payer: United Healthcare All Other HMO |
$350.69
|
| Rate for Payer: United Healthcare HMO Rider |
$343.10
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$314.40
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$816.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$816.00
|
| Rate for Payer: Vantage Medical Group Senior |
$816.00
|
|
|
GOLODIRSEN 50 MG/ML INTRAVENOUS SOLUTION [226694]
|
Facility
|
IP
|
$960.00
|
|
|
Service Code
|
HCPCS J1429
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$192.00 |
| Max. Negotiated Rate |
$816.00 |
| Rate for Payer: Adventist Health Commercial |
$192.00
|
| Rate for Payer: Blue Shield of California Commercial |
$486.72
|
| Rate for Payer: Blue Shield of California Commercial |
$738.24
|
| Rate for Payer: Cash Price |
$432.00
|
| Rate for Payer: Cigna of CA HMO |
$672.00
|
| Rate for Payer: Cigna of CA PPO |
$672.00
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$672.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$384.00
|
| Rate for Payer: EPIC Health Plan Senior |
$384.00
|
| Rate for Payer: Galaxy Health WC |
$816.00
|
| Rate for Payer: Global Benefits Group Commercial |
$576.00
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$609.60
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$566.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$230.40
|
| Rate for Payer: Multiplan Commercial |
$768.00
|
| Rate for Payer: Networks By Design Commercial |
$480.00
|
| Rate for Payer: Prime Health Services Commercial |
$816.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$360.29
|
| Rate for Payer: United Healthcare All Other HMO |
$350.69
|
| Rate for Payer: United Healthcare HMO Rider |
$343.10
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$314.40
|
|
|
GOSERELIN 10.8 MG SUBCUTANEOUS IMPLANT [16254]
|
Facility
|
IP
|
$3,855.49
|
|
|
Service Code
|
HCPCS J9202
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$771.10 |
| Max. Negotiated Rate |
$3,277.17 |
| Rate for Payer: EPIC Health Plan Commercial |
$1,542.20
|
| Rate for Payer: EPIC Health Plan Senior |
$1,542.20
|
| Rate for Payer: Galaxy Health WC |
$3,277.17
|
| Rate for Payer: Adventist Health Commercial |
$771.10
|
| Rate for Payer: Blue Shield of California Commercial |
$1,954.73
|
| Rate for Payer: Blue Shield of California Commercial |
$2,964.87
|
| Rate for Payer: Cash Price |
$1,734.97
|
| Rate for Payer: Cigna of CA HMO |
$2,698.84
|
| Rate for Payer: Cigna of CA PPO |
$2,698.84
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$2,698.84
|
| Rate for Payer: Global Benefits Group Commercial |
$2,313.29
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$2,448.24
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2,274.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$925.32
|
| Rate for Payer: Multiplan Commercial |
$3,084.39
|
| Rate for Payer: Networks By Design Commercial |
$1,927.74
|
| Rate for Payer: Prime Health Services Commercial |
$3,277.17
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,446.97
|
| Rate for Payer: United Healthcare All Other HMO |
$1,408.41
|
| Rate for Payer: United Healthcare HMO Rider |
$1,377.95
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,262.67
|
|
|
GOSERELIN 10.8 MG SUBCUTANEOUS IMPLANT [16254]
|
Facility
|
OP
|
$3,855.49
|
|
|
Service Code
|
HCPCS J9202
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$771.10 |
| Max. Negotiated Rate |
$3,277.17 |
| Rate for Payer: Adventist Health Commercial |
$771.10
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1,388.77
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,277.17
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,120.52
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,891.62
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,111.95
|
| Rate for Payer: Blue Shield of California Commercial |
$1,152.42
|
| Rate for Payer: Cash Price |
$1,734.97
|
| Rate for Payer: Cash Price |
$1,734.97
|
| Rate for Payer: Cigna of CA HMO |
$2,698.84
|
| Rate for Payer: Cigna of CA PPO |
$2,698.84
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,277.17
|
| Rate for Payer: Dignity Health Medi-Cal |
$3,277.17
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3,277.17
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$2,698.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,542.20
|
| Rate for Payer: EPIC Health Plan Senior |
$1,542.20
|
| Rate for Payer: Galaxy Health WC |
$3,277.17
|
| Rate for Payer: Global Benefits Group Commercial |
$2,313.29
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$1,306.20
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$2,448.24
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1,477.25
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2,274.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$925.32
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,698.84
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,698.84
|
| Rate for Payer: Multiplan Commercial |
$3,084.39
|
| Rate for Payer: Networks By Design Commercial |
$1,927.74
|
| Rate for Payer: Prime Health Services Commercial |
$3,277.17
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2,313.29
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2,313.29
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,446.97
|
| Rate for Payer: United Healthcare All Other HMO |
$1,408.41
|
| Rate for Payer: United Healthcare HMO Rider |
$1,377.95
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,262.67
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,277.17
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3,277.17
|
| Rate for Payer: Vantage Medical Group Senior |
$3,277.17
|
|
|
GOSERELIN 3.6 MG SUBCUTANEOUS IMPLANT [10137]
|
Facility
|
OP
|
$1,414.82
|
|
|
Service Code
|
HCPCS J9202
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$282.96 |
| Max. Negotiated Rate |
$1,477.25 |
| Rate for Payer: Cash Price |
$636.67
|
| Rate for Payer: Cash Price |
$636.67
|
| Rate for Payer: Cigna of CA HMO |
$990.37
|
| Rate for Payer: Cigna of CA PPO |
$990.37
|
| Rate for Payer: Adventist Health Commercial |
$282.96
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1,388.77
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,202.60
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$778.15
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,061.12
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,111.95
|
| Rate for Payer: Blue Shield of California Commercial |
$1,152.42
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,202.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,202.60
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1,202.60
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$990.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$565.93
|
| Rate for Payer: EPIC Health Plan Senior |
$565.93
|
| Rate for Payer: Galaxy Health WC |
$1,202.60
|
| Rate for Payer: Global Benefits Group Commercial |
$848.89
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$1,306.20
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$898.41
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1,477.25
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$834.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$339.56
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$990.37
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$990.37
|
| Rate for Payer: Multiplan Commercial |
$1,131.86
|
| Rate for Payer: Networks By Design Commercial |
$707.41
|
| Rate for Payer: Prime Health Services Commercial |
$1,202.60
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$848.89
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$848.89
|
| Rate for Payer: United Healthcare All Other Commercial |
$530.98
|
| Rate for Payer: United Healthcare All Other HMO |
$516.83
|
| Rate for Payer: United Healthcare HMO Rider |
$505.66
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$463.35
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,202.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,202.60
|
| Rate for Payer: Vantage Medical Group Senior |
$1,202.60
|
|
|
GOSERELIN 3.6 MG SUBCUTANEOUS IMPLANT [10137]
|
Facility
|
IP
|
$1,414.82
|
|
|
Service Code
|
HCPCS J9202
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$282.96 |
| Max. Negotiated Rate |
$1,202.60 |
| Rate for Payer: Adventist Health Commercial |
$282.96
|
| Rate for Payer: Blue Shield of California Commercial |
$1,088.00
|
| Rate for Payer: Blue Shield of California Commercial |
$717.31
|
| Rate for Payer: Cash Price |
$636.67
|
| Rate for Payer: Cigna of CA HMO |
$990.37
|
| Rate for Payer: Cigna of CA PPO |
$990.37
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$990.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$565.93
|
| Rate for Payer: EPIC Health Plan Senior |
$565.93
|
| Rate for Payer: Galaxy Health WC |
$1,202.60
|
| Rate for Payer: Global Benefits Group Commercial |
$848.89
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$898.41
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$834.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$339.56
|
| Rate for Payer: Multiplan Commercial |
$1,131.86
|
| Rate for Payer: Networks By Design Commercial |
$707.41
|
| Rate for Payer: Prime Health Services Commercial |
$1,202.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$530.98
|
| Rate for Payer: United Healthcare All Other HMO |
$516.83
|
| Rate for Payer: United Healthcare HMO Rider |
$505.66
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$463.35
|
|
|
GRAFT; EAR CARTILAGE, AUTOGENOUS, TO NOSE OR EAR (INCLUDES OBTAINING GRAFT)
|
Facility
|
OP
|
$32,312.00
|
|
|
Service Code
|
CPT 21235
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$170.13 |
| Max. Negotiated Rate |
$32,312.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$32,312.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$11,420.83
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8,375.28
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$7,613.89
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,240.00
|
| Rate for Payer: Blue Shield of California Commercial |
$8,695.24
|
| Rate for Payer: Blue Shield of California Commercial |
$5,743.74
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11,420.83
|
| Rate for Payer: Dignity Health Medi-Cal |
$8,375.28
|
| Rate for Payer: Dignity Health Medicare Advantage |
$7,613.89
|
| Rate for Payer: EPIC Health Plan Commercial |
$12,562.92
|
| Rate for Payer: EPIC Health Plan Senior |
$8,375.28
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$12,486.78
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$170.13
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$7,613.89
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$192.41
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$10,659.45
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$9,593.50
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$10,202.61
|
| Rate for Payer: Multiplan WC |
$11,976.10
|
| Rate for Payer: Prime Health Services WC |
$11,853.89
|
| Rate for Payer: United Healthcare All Other HMO |
$7,378.00
|
| Rate for Payer: United Healthcare HMO Rider |
$4,428.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4,122.00
|
| Rate for Payer: Upland Medical Group Pediatric |
$7,613.89
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$11,420.83
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8,375.28
|
| Rate for Payer: Vantage Medical Group Senior |
$7,613.89
|
|
|
GRAFTING OF AUTOLOGOUS FAT HARVESTED BY LIPOSUCTION TECHNIQUE TO FACE, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, AND/OR FEET; 25 CC OR LESS INJECTATE
|
Facility
|
OP
|
$32,312.00
|
|
|
Service Code
|
CPT 15773
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$871.26 |
| Max. Negotiated Rate |
$32,312.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$32,312.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,980.58
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,919.09
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,653.72
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,240.00
|
| Rate for Payer: Blue Shield of California Commercial |
$1,924.01
|
| Rate for Payer: Blue Shield of California Commercial |
$2,912.69
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,980.58
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,919.09
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2,653.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$4,378.64
|
| Rate for Payer: EPIC Health Plan Senior |
$2,919.09
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$4,352.10
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$871.26
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2,653.72
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$985.36
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$3,715.21
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3,343.69
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3,555.98
|
| Rate for Payer: Multiplan WC |
$3,703.23
|
| Rate for Payer: Prime Health Services WC |
$3,665.45
|
| Rate for Payer: United Healthcare All Other HMO |
$7,378.00
|
| Rate for Payer: United Healthcare HMO Rider |
$4,428.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4,122.00
|
| Rate for Payer: Upland Medical Group Pediatric |
$2,653.72
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,980.58
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,919.09
|
| Rate for Payer: Vantage Medical Group Senior |
$2,653.72
|
|
|
GRAFTING OF AUTOLOGOUS SOFT TISSUE, OTHER, HARVESTED BY DIRECT EXCISION (EG, FAT, DERMIS, FASCIA)
|
Facility
|
OP
|
$32,312.00
|
|
|
Service Code
|
CPT 15769
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$141.98 |
| Max. Negotiated Rate |
$32,312.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$32,312.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6,836.73
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5,013.60
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4,557.82
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9,104.00
|
| Rate for Payer: Blue Shield of California Commercial |
$7,730.00
|
| Rate for Payer: Blue Shield of California Commercial |
$11,702.17
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,836.73
|
| Rate for Payer: Dignity Health Medi-Cal |
$5,013.60
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4,557.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$7,520.40
|
| Rate for Payer: EPIC Health Plan Senior |
$5,013.60
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$7,474.82
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$141.98
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4,557.82
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$160.57
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$6,380.95
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5,742.85
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$6,107.48
|
| Rate for Payer: Multiplan WC |
$7,411.53
|
| Rate for Payer: Prime Health Services WC |
$7,335.91
|
| Rate for Payer: United Healthcare All Other HMO |
$20,902.00
|
| Rate for Payer: United Healthcare HMO Rider |
$13,066.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$11,971.00
|
| Rate for Payer: Upland Medical Group Pediatric |
$4,557.82
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,836.73
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5,013.60
|
| Rate for Payer: Vantage Medical Group Senior |
$4,557.82
|
|
|
GRANISETRON HCL 1 MG/ML (1 ML) INTRAVENOUS SOLUTION [12552]
|
Facility
|
OP
|
$10.80
|
|
|
Service Code
|
HCPCS J1626
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$44.05 |
| Rate for Payer: Adventist Health Commercial |
$2.16
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.62
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$9.18
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5.94
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$8.10
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$44.05
|
| Rate for Payer: Blue Shield of California Commercial |
$1.08
|
| Rate for Payer: Cash Price |
$4.86
|
| Rate for Payer: Cash Price |
$4.86
|
| Rate for Payer: Cigna of CA HMO |
$7.56
|
| Rate for Payer: Cigna of CA PPO |
$7.56
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.18
|
| Rate for Payer: Dignity Health Medicare Advantage |
$9.18
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$7.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.32
|
| Rate for Payer: EPIC Health Plan Senior |
$4.32
|
| Rate for Payer: Galaxy Health WC |
$9.18
|
| Rate for Payer: Global Benefits Group Commercial |
$6.48
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.20
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$6.86
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.29
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$6.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.59
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$7.56
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$7.56
|
| Rate for Payer: Multiplan Commercial |
$8.64
|
| Rate for Payer: Networks By Design Commercial |
$5.40
|
| Rate for Payer: Prime Health Services Commercial |
$9.18
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$6.48
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$6.48
|
| Rate for Payer: United Healthcare All Other Commercial |
$4.05
|
| Rate for Payer: United Healthcare All Other HMO |
$3.95
|
| Rate for Payer: United Healthcare HMO Rider |
$3.86
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.54
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$9.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.18
|
| Rate for Payer: Vantage Medical Group Senior |
$9.18
|
|
|
GRANISETRON HCL 1 MG/ML (1 ML) INTRAVENOUS SOLUTION [12552]
|
Facility
|
IP
|
$10.80
|
|
|
Service Code
|
HCPCS J1626
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.16 |
| Max. Negotiated Rate |
$9.18 |
| Rate for Payer: Adventist Health Commercial |
$2.16
|
| Rate for Payer: Blue Shield of California Commercial |
$5.48
|
| Rate for Payer: Blue Shield of California Commercial |
$8.31
|
| Rate for Payer: Cash Price |
$4.86
|
| Rate for Payer: Cigna of CA HMO |
$7.56
|
| Rate for Payer: Cigna of CA PPO |
$7.56
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$7.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.32
|
| Rate for Payer: EPIC Health Plan Senior |
$4.32
|
| Rate for Payer: Galaxy Health WC |
$9.18
|
| Rate for Payer: Global Benefits Group Commercial |
$6.48
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$6.86
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$6.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.59
|
| Rate for Payer: Multiplan Commercial |
$8.64
|
| Rate for Payer: Networks By Design Commercial |
$5.40
|
| Rate for Payer: Prime Health Services Commercial |
$9.18
|
| Rate for Payer: United Healthcare All Other Commercial |
$4.05
|
| Rate for Payer: United Healthcare All Other HMO |
$3.95
|
| Rate for Payer: United Healthcare HMO Rider |
$3.86
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.54
|
|
|
GRANISETRON HCL 1 MG/ML INTRAVENOUS SOLUTION [92107]
|
Facility
|
IP
|
$10.80
|
|
|
Service Code
|
HCPCS J1626
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.16 |
| Max. Negotiated Rate |
$9.18 |
| Rate for Payer: Adventist Health Commercial |
$2.16
|
| Rate for Payer: Blue Shield of California Commercial |
$5.48
|
| Rate for Payer: Blue Shield of California Commercial |
$8.31
|
| Rate for Payer: Cash Price |
$4.86
|
| Rate for Payer: Cigna of CA HMO |
$7.56
|
| Rate for Payer: Cigna of CA PPO |
$7.56
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$7.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.32
|
| Rate for Payer: EPIC Health Plan Senior |
$4.32
|
| Rate for Payer: Galaxy Health WC |
$9.18
|
| Rate for Payer: Global Benefits Group Commercial |
$6.48
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$6.86
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$6.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.59
|
| Rate for Payer: Multiplan Commercial |
$8.64
|
| Rate for Payer: Networks By Design Commercial |
$5.40
|
| Rate for Payer: Prime Health Services Commercial |
$9.18
|
| Rate for Payer: United Healthcare All Other Commercial |
$4.05
|
| Rate for Payer: United Healthcare All Other HMO |
$3.95
|
| Rate for Payer: United Healthcare HMO Rider |
$3.86
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.54
|
|
|
GRANISETRON HCL 1 MG/ML INTRAVENOUS SOLUTION [92107]
|
Facility
|
OP
|
$10.80
|
|
|
Service Code
|
HCPCS J1626
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$44.05 |
| Rate for Payer: Adventist Health Commercial |
$2.16
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.62
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$9.18
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5.94
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$8.10
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$44.05
|
| Rate for Payer: Blue Shield of California Commercial |
$1.08
|
| Rate for Payer: Cash Price |
$4.86
|
| Rate for Payer: Cash Price |
$4.86
|
| Rate for Payer: Cigna of CA HMO |
$7.56
|
| Rate for Payer: Cigna of CA PPO |
$7.56
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.18
|
| Rate for Payer: Dignity Health Medicare Advantage |
$9.18
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$7.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.32
|
| Rate for Payer: EPIC Health Plan Senior |
$4.32
|
| Rate for Payer: Galaxy Health WC |
$9.18
|
| Rate for Payer: Global Benefits Group Commercial |
$6.48
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.20
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$6.86
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.29
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$6.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.59
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$7.56
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$7.56
|
| Rate for Payer: Multiplan Commercial |
$8.64
|
| Rate for Payer: Networks By Design Commercial |
$5.40
|
| Rate for Payer: Prime Health Services Commercial |
$9.18
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$6.48
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$6.48
|
| Rate for Payer: United Healthcare All Other Commercial |
$4.05
|
| Rate for Payer: United Healthcare All Other HMO |
$3.95
|
| Rate for Payer: United Healthcare HMO Rider |
$3.86
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.54
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$9.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.18
|
| Rate for Payer: Vantage Medical Group Senior |
$9.18
|
|
|
GRANISETRON HCL 1 MG TABLET [14720]
|
Facility
|
IP
|
$4.32
|
|
|
Service Code
|
NDC 5199173520
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.86 |
| Max. Negotiated Rate |
$3.67 |
| Rate for Payer: Adventist Health Commercial |
$0.86
|
| Rate for Payer: Blue Shield of California Commercial |
$2.19
|
| Rate for Payer: Blue Shield of California Commercial |
$3.32
|
| Rate for Payer: Cash Price |
$1.94
|
| Rate for Payer: Cigna of CA HMO |
$3.02
|
| Rate for Payer: Cigna of CA PPO |
$3.02
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$3.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.73
|
| Rate for Payer: EPIC Health Plan Senior |
$1.73
|
| Rate for Payer: Galaxy Health WC |
$3.67
|
| Rate for Payer: Global Benefits Group Commercial |
$2.59
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$2.74
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.04
|
| Rate for Payer: Multiplan Commercial |
$3.46
|
| Rate for Payer: Networks By Design Commercial |
$2.81
|
| Rate for Payer: Prime Health Services Commercial |
$3.67
|
|
|
GRANISETRON HCL 1 MG TABLET [14720]
|
Facility
|
IP
|
$4.32
|
|
|
Service Code
|
NDC 5199173599
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.86 |
| Max. Negotiated Rate |
$3.67 |
| Rate for Payer: Adventist Health Commercial |
$0.86
|
| Rate for Payer: Blue Shield of California Commercial |
$2.19
|
| Rate for Payer: Blue Shield of California Commercial |
$3.32
|
| Rate for Payer: Cash Price |
$1.94
|
| Rate for Payer: Cigna of CA HMO |
$3.02
|
| Rate for Payer: Cigna of CA PPO |
$3.02
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$3.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.73
|
| Rate for Payer: EPIC Health Plan Senior |
$1.73
|
| Rate for Payer: Galaxy Health WC |
$3.67
|
| Rate for Payer: Global Benefits Group Commercial |
$2.59
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$2.74
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.04
|
| Rate for Payer: Multiplan Commercial |
$3.46
|
| Rate for Payer: Networks By Design Commercial |
$2.81
|
| Rate for Payer: Prime Health Services Commercial |
$3.67
|
|
|
GRANISETRON HCL 1 MG TABLET [14720]
|
Facility
|
OP
|
$4.32
|
|
|
Service Code
|
NDC 5199173599
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.86 |
| Max. Negotiated Rate |
$3.67 |
| Rate for Payer: Adventist Health Commercial |
$0.86
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2.83
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.67
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.38
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.24
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.77
|
| Rate for Payer: Cash Price |
$1.94
|
| Rate for Payer: Cigna of CA HMO |
$3.02
|
| Rate for Payer: Cigna of CA PPO |
$3.02
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.67
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.67
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3.67
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$3.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.73
|
| Rate for Payer: EPIC Health Plan Senior |
$1.73
|
| Rate for Payer: Galaxy Health WC |
$3.67
|
| Rate for Payer: Global Benefits Group Commercial |
$2.59
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$2.74
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.57
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.04
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3.02
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3.02
|
| Rate for Payer: Multiplan Commercial |
$3.46
|
| Rate for Payer: Networks By Design Commercial |
$2.81
|
| Rate for Payer: Prime Health Services Commercial |
$3.67
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.59
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.59
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.16
|
| Rate for Payer: United Healthcare All Other HMO |
$2.16
|
| Rate for Payer: United Healthcare HMO Rider |
$2.16
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.16
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.67
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.67
|
| Rate for Payer: Vantage Medical Group Senior |
$3.67
|
|
