|
KIT FOR TC 99M-LABELED RED BLOOD CELLS INTRAVENOUS SOLUTION [225270]
|
Facility
|
OP
|
$181.13
|
|
|
Service Code
|
HCPCS A9560
|
| Hospital Charge Code |
901700057
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$36.23 |
| Max. Negotiated Rate |
$163.02 |
| Rate for Payer: Adventist Health Commercial |
$36.23
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$153.96
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$99.62
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$135.85
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$87.70
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$106.38
|
| Rate for Payer: Blue Shield of California Commercial |
$109.95
|
| Rate for Payer: Blue Shield of California EPN |
$71.91
|
| Rate for Payer: Cash Price |
$99.62
|
| Rate for Payer: Cash Price |
$99.62
|
| Rate for Payer: Central Health Plan Commercial |
$144.90
|
| Rate for Payer: Cigna of CA HMO |
$115.92
|
| Rate for Payer: Cigna of CA PPO |
$134.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$153.96
|
| Rate for Payer: Dignity Health Medi-Cal |
$153.96
|
| Rate for Payer: Dignity Health Medicare Advantage |
$153.96
|
| Rate for Payer: EPIC Health Plan Commercial |
$72.45
|
| Rate for Payer: EPIC Health Plan Senior |
$72.45
|
| Rate for Payer: Galaxy Health WC |
$153.96
|
| Rate for Payer: Global Benefits Group Commercial |
$108.68
|
| Rate for Payer: Health Management Network EPO/PPO |
$163.02
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$89.10
|
| Rate for Payer: InnovAge PACE Commercial |
$90.56
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$120.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$98.42
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$112.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$36.23
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$126.79
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$126.79
|
| Rate for Payer: Multiplan Commercial |
$135.85
|
| Rate for Payer: Networks By Design Commercial |
$117.73
|
| Rate for Payer: Prime Health Services Commercial |
$153.96
|
| Rate for Payer: Riverside University Health System MISP |
$72.45
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$108.68
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$108.68
|
| Rate for Payer: United Healthcare All Other Commercial |
$67.98
|
| Rate for Payer: United Healthcare All Other HMO |
$66.17
|
| Rate for Payer: United Healthcare HMO Rider |
$64.74
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$59.32
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$153.96
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$153.96
|
| Rate for Payer: Vantage Medical Group Senior |
$153.96
|
|
|
KIT FOR TC 99M-LABELED RED BLOOD CELLS INTRAVENOUS SOLUTION [225270]
|
Facility
|
IP
|
$181.13
|
|
|
Service Code
|
HCPCS A9560
|
| Hospital Charge Code |
901700057
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$36.23 |
| Max. Negotiated Rate |
$163.02 |
| Rate for Payer: Adventist Health Commercial |
$36.23
|
| Rate for Payer: Blue Shield of California Commercial |
$140.01
|
| Rate for Payer: Blue Shield of California EPN |
$91.29
|
| Rate for Payer: Cash Price |
$99.62
|
| Rate for Payer: Central Health Plan Commercial |
$144.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$72.45
|
| Rate for Payer: EPIC Health Plan Senior |
$72.45
|
| Rate for Payer: Galaxy Health WC |
$153.96
|
| Rate for Payer: Global Benefits Group Commercial |
$108.68
|
| Rate for Payer: Health Management Network EPO/PPO |
$163.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$120.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$69.01
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$112.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$36.23
|
| Rate for Payer: Multiplan Commercial |
$135.85
|
| Rate for Payer: Networks By Design Commercial |
$117.73
|
| Rate for Payer: Prime Health Services Commercial |
$153.96
|
| Rate for Payer: United Healthcare All Other Commercial |
$67.98
|
| Rate for Payer: United Healthcare All Other HMO |
$66.17
|
| Rate for Payer: United Healthcare HMO Rider |
$64.74
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$59.32
|
|
|
KIT FOR THE PREPARATION OF TC-99M-MEBROFENIN 45 MG IV SOLUTION [121131]
|
Facility
|
IP
|
$90.00
|
|
|
Service Code
|
HCPCS A9537
|
| Hospital Charge Code |
901700057
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$18.00 |
| Max. Negotiated Rate |
$81.00 |
| Rate for Payer: Adventist Health Commercial |
$18.00
|
| Rate for Payer: Blue Shield of California Commercial |
$69.57
|
| Rate for Payer: Blue Shield of California EPN |
$45.36
|
| Rate for Payer: Cash Price |
$49.50
|
| Rate for Payer: Central Health Plan Commercial |
$72.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$36.00
|
| Rate for Payer: EPIC Health Plan Senior |
$36.00
|
| Rate for Payer: Galaxy Health WC |
$76.50
|
| Rate for Payer: Global Benefits Group Commercial |
$54.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$81.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$60.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$34.29
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$55.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$18.00
|
| Rate for Payer: Multiplan Commercial |
$67.50
|
| Rate for Payer: Networks By Design Commercial |
$58.50
|
| Rate for Payer: Prime Health Services Commercial |
$76.50
|
| Rate for Payer: United Healthcare All Other Commercial |
$33.78
|
| Rate for Payer: United Healthcare All Other HMO |
$32.88
|
| Rate for Payer: United Healthcare HMO Rider |
$32.17
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$29.48
|
|
|
KIT FOR THE PREPARATION OF TC-99M-MEBROFENIN 45 MG IV SOLUTION [121131]
|
Facility
|
OP
|
$90.00
|
|
|
Service Code
|
HCPCS A9537
|
| Hospital Charge Code |
901700057
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$18.00 |
| Max. Negotiated Rate |
$86.18 |
| Rate for Payer: Adventist Health Commercial |
$18.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$76.50
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$49.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$67.50
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$43.58
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$52.86
|
| Rate for Payer: Blue Shield of California Commercial |
$54.63
|
| Rate for Payer: Blue Shield of California EPN |
$35.73
|
| Rate for Payer: Cash Price |
$49.50
|
| Rate for Payer: Cash Price |
$49.50
|
| Rate for Payer: Central Health Plan Commercial |
$72.00
|
| Rate for Payer: Cigna of CA HMO |
$57.60
|
| Rate for Payer: Cigna of CA PPO |
$66.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$76.50
|
| Rate for Payer: Dignity Health Medi-Cal |
$76.50
|
| Rate for Payer: Dignity Health Medicare Advantage |
$76.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$36.00
|
| Rate for Payer: EPIC Health Plan Senior |
$36.00
|
| Rate for Payer: Galaxy Health WC |
$76.50
|
| Rate for Payer: Global Benefits Group Commercial |
$54.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$81.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$78.02
|
| Rate for Payer: InnovAge PACE Commercial |
$45.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$60.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$86.18
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$55.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$18.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$63.00
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$63.00
|
| Rate for Payer: Multiplan Commercial |
$67.50
|
| Rate for Payer: Networks By Design Commercial |
$58.50
|
| Rate for Payer: Prime Health Services Commercial |
$76.50
|
| Rate for Payer: Riverside University Health System MISP |
$36.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$54.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$54.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$33.78
|
| Rate for Payer: United Healthcare All Other HMO |
$32.88
|
| Rate for Payer: United Healthcare HMO Rider |
$32.17
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$29.48
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$76.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$76.50
|
| Rate for Payer: Vantage Medical Group Senior |
$76.50
|
|
|
KIT FOR THE PREPARATION OF TC-99M-TETROFOSMIN 0.23 MG IV SOLUTION [98467]
|
Facility
|
OP
|
$818.62
|
|
|
Service Code
|
HCPCS A9502
|
| Hospital Charge Code |
901700057
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$163.72 |
| Max. Negotiated Rate |
$736.76 |
| Rate for Payer: Adventist Health Commercial |
$163.72
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$695.83
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$450.24
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$613.97
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$396.38
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$480.78
|
| Rate for Payer: Blue Shield of California Commercial |
$496.90
|
| Rate for Payer: Blue Shield of California EPN |
$324.99
|
| Rate for Payer: Cash Price |
$450.24
|
| Rate for Payer: Cash Price |
$450.24
|
| Rate for Payer: Central Health Plan Commercial |
$654.90
|
| Rate for Payer: Cigna of CA HMO |
$523.92
|
| Rate for Payer: Cigna of CA PPO |
$605.78
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$695.83
|
| Rate for Payer: Dignity Health Medi-Cal |
$695.83
|
| Rate for Payer: Dignity Health Medicare Advantage |
$695.83
|
| Rate for Payer: EPIC Health Plan Commercial |
$327.45
|
| Rate for Payer: EPIC Health Plan Senior |
$327.45
|
| Rate for Payer: Galaxy Health WC |
$695.83
|
| Rate for Payer: Global Benefits Group Commercial |
$491.17
|
| Rate for Payer: Health Management Network EPO/PPO |
$736.76
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$166.56
|
| Rate for Payer: InnovAge PACE Commercial |
$409.31
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$546.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$184.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$506.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$163.72
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$573.03
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$573.03
|
| Rate for Payer: Multiplan Commercial |
$613.97
|
| Rate for Payer: Networks By Design Commercial |
$532.10
|
| Rate for Payer: Prime Health Services Commercial |
$695.83
|
| Rate for Payer: Riverside University Health System MISP |
$327.45
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$491.17
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$491.17
|
| Rate for Payer: United Healthcare All Other Commercial |
$307.23
|
| Rate for Payer: United Healthcare All Other HMO |
$299.04
|
| Rate for Payer: United Healthcare HMO Rider |
$292.57
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$268.10
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$695.83
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$695.83
|
| Rate for Payer: Vantage Medical Group Senior |
$695.83
|
|
|
KIT FOR THE PREPARATION OF TC-99M-TETROFOSMIN 0.23 MG IV SOLUTION [98467]
|
Facility
|
IP
|
$818.62
|
|
|
Service Code
|
HCPCS A9502
|
| Hospital Charge Code |
901700057
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$163.72 |
| Max. Negotiated Rate |
$736.76 |
| Rate for Payer: Adventist Health Commercial |
$163.72
|
| Rate for Payer: Blue Shield of California Commercial |
$632.79
|
| Rate for Payer: Blue Shield of California EPN |
$412.58
|
| Rate for Payer: Cash Price |
$450.24
|
| Rate for Payer: Central Health Plan Commercial |
$654.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$327.45
|
| Rate for Payer: EPIC Health Plan Senior |
$327.45
|
| Rate for Payer: Galaxy Health WC |
$695.83
|
| Rate for Payer: Global Benefits Group Commercial |
$491.17
|
| Rate for Payer: Health Management Network EPO/PPO |
$736.76
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$546.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$311.89
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$506.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$163.72
|
| Rate for Payer: Multiplan Commercial |
$613.97
|
| Rate for Payer: Networks By Design Commercial |
$532.10
|
| Rate for Payer: Prime Health Services Commercial |
$695.83
|
| Rate for Payer: United Healthcare All Other Commercial |
$307.23
|
| Rate for Payer: United Healthcare All Other HMO |
$299.04
|
| Rate for Payer: United Healthcare HMO Rider |
$292.57
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$268.10
|
|
|
KIT FOR THE PREP OF TC-99M-TILMANOCEPT 250 MCG SOLUTION FOR INJECTION [223025]
|
Facility
|
IP
|
$755.82
|
|
|
Service Code
|
HCPCS A9520
|
| Hospital Charge Code |
901700057
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$151.16 |
| Max. Negotiated Rate |
$680.24 |
| Rate for Payer: Adventist Health Commercial |
$151.16
|
| Rate for Payer: Blue Shield of California Commercial |
$584.25
|
| Rate for Payer: Blue Shield of California EPN |
$380.93
|
| Rate for Payer: Cash Price |
$415.70
|
| Rate for Payer: Central Health Plan Commercial |
$604.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$302.33
|
| Rate for Payer: EPIC Health Plan Senior |
$302.33
|
| Rate for Payer: Galaxy Health WC |
$642.45
|
| Rate for Payer: Global Benefits Group Commercial |
$453.49
|
| Rate for Payer: Health Management Network EPO/PPO |
$680.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$504.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$287.97
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$467.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$151.16
|
| Rate for Payer: Multiplan Commercial |
$566.87
|
| Rate for Payer: Networks By Design Commercial |
$491.28
|
| Rate for Payer: Prime Health Services Commercial |
$642.45
|
| Rate for Payer: United Healthcare All Other Commercial |
$283.66
|
| Rate for Payer: United Healthcare All Other HMO |
$276.10
|
| Rate for Payer: United Healthcare HMO Rider |
$270.13
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$247.53
|
|
|
KIT FOR THE PREP OF TC-99M-TILMANOCEPT 250 MCG SOLUTION FOR INJECTION [223025]
|
Facility
|
OP
|
$755.82
|
|
|
Service Code
|
HCPCS A9520
|
| Hospital Charge Code |
901700057
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$151.16 |
| Max. Negotiated Rate |
$680.24 |
| Rate for Payer: Adventist Health Commercial |
$151.16
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$642.45
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$415.70
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$566.87
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$365.97
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$443.89
|
| Rate for Payer: Blue Shield of California Commercial |
$458.78
|
| Rate for Payer: Blue Shield of California EPN |
$300.06
|
| Rate for Payer: Cash Price |
$415.70
|
| Rate for Payer: Central Health Plan Commercial |
$604.66
|
| Rate for Payer: Cigna of CA HMO |
$483.72
|
| Rate for Payer: Cigna of CA PPO |
$559.31
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$642.45
|
| Rate for Payer: Dignity Health Medi-Cal |
$642.45
|
| Rate for Payer: Dignity Health Medicare Advantage |
$642.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$302.33
|
| Rate for Payer: EPIC Health Plan Senior |
$302.33
|
| Rate for Payer: Galaxy Health WC |
$642.45
|
| Rate for Payer: Global Benefits Group Commercial |
$453.49
|
| Rate for Payer: Health Management Network EPO/PPO |
$680.24
|
| Rate for Payer: InnovAge PACE Commercial |
$377.91
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$504.13
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$467.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$151.16
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$529.07
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$529.07
|
| Rate for Payer: Multiplan Commercial |
$566.87
|
| Rate for Payer: Networks By Design Commercial |
$491.28
|
| Rate for Payer: Prime Health Services Commercial |
$642.45
|
| Rate for Payer: Riverside University Health System MISP |
$302.33
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$453.49
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$453.49
|
| Rate for Payer: United Healthcare All Other Commercial |
$283.66
|
| Rate for Payer: United Healthcare All Other HMO |
$276.10
|
| Rate for Payer: United Healthcare HMO Rider |
$270.13
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$247.53
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$642.45
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$642.45
|
| Rate for Payer: Vantage Medical Group Senior |
$642.45
|
|
|
KIT OSTOMY SENSURA FLEX
|
Facility
|
OP
|
$13.20
|
|
|
Service Code
|
CPT A4414
|
| Hospital Charge Code |
901698223
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2.64 |
| Max. Negotiated Rate |
$11.88 |
| Rate for Payer: Adventist Health Commercial |
$2.64
|
| Rate for Payer: Aetna of CA HMO/PPO |
$8.02
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$11.22
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7.26
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9.90
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$6.39
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7.75
|
| Rate for Payer: Blue Shield of California Commercial |
$8.07
|
| Rate for Payer: Blue Shield of California EPN |
$5.27
|
| Rate for Payer: Cash Price |
$7.26
|
| Rate for Payer: Central Health Plan Commercial |
$10.56
|
| Rate for Payer: Cigna of CA HMO |
$8.45
|
| Rate for Payer: Cigna of CA PPO |
$9.77
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$11.22
|
| Rate for Payer: Dignity Health Medicare Advantage |
$11.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.28
|
| Rate for Payer: EPIC Health Plan Senior |
$5.28
|
| Rate for Payer: Galaxy Health WC |
$11.22
|
| Rate for Payer: Global Benefits Group Commercial |
$7.92
|
| Rate for Payer: Health Management Network EPO/PPO |
$11.88
|
| Rate for Payer: InnovAge PACE Commercial |
$6.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$8.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.03
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$8.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.64
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$9.24
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$9.24
|
| Rate for Payer: Multiplan Commercial |
$9.90
|
| Rate for Payer: Networks By Design Commercial |
$8.58
|
| Rate for Payer: Prime Health Services Commercial |
$11.22
|
| Rate for Payer: Riverside University Health System MISP |
$5.28
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$7.92
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$7.92
|
| Rate for Payer: United Healthcare All Other Commercial |
$6.60
|
| Rate for Payer: United Healthcare All Other HMO |
$6.60
|
| Rate for Payer: United Healthcare HMO Rider |
$6.60
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6.60
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$11.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$11.22
|
| Rate for Payer: Vantage Medical Group Senior |
$11.22
|
|
|
KIT OSTOMY SENSURA FLEX
|
Facility
|
IP
|
$13.20
|
|
|
Service Code
|
CPT A4414
|
| Hospital Charge Code |
901698223
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2.64 |
| Max. Negotiated Rate |
$11.88 |
| Rate for Payer: Adventist Health Commercial |
$2.64
|
| Rate for Payer: Cash Price |
$7.26
|
| Rate for Payer: Central Health Plan Commercial |
$10.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.28
|
| Rate for Payer: EPIC Health Plan Senior |
$5.28
|
| Rate for Payer: Galaxy Health WC |
$11.22
|
| Rate for Payer: Global Benefits Group Commercial |
$7.92
|
| Rate for Payer: Health Management Network EPO/PPO |
$11.88
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$8.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.03
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$8.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.64
|
| Rate for Payer: Multiplan Commercial |
$9.90
|
| Rate for Payer: Networks By Design Commercial |
$8.58
|
| Rate for Payer: Prime Health Services Commercial |
$11.22
|
|
|
KIT PREPARATION OF TC 99M-SESTAMIBI COMBO NO.1 IV SOLUTION [121547]
|
Facility
|
IP
|
$36.00
|
|
|
Service Code
|
HCPCS A9500
|
| Hospital Charge Code |
901700057
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$7.20 |
| Max. Negotiated Rate |
$32.40 |
| Rate for Payer: Adventist Health Commercial |
$7.20
|
| Rate for Payer: Blue Shield of California Commercial |
$27.83
|
| Rate for Payer: Blue Shield of California EPN |
$18.14
|
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Central Health Plan Commercial |
$28.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.40
|
| Rate for Payer: EPIC Health Plan Senior |
$14.40
|
| Rate for Payer: Galaxy Health WC |
$30.60
|
| Rate for Payer: Global Benefits Group Commercial |
$21.60
|
| Rate for Payer: Health Management Network EPO/PPO |
$32.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$24.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$13.72
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$22.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.20
|
| Rate for Payer: Multiplan Commercial |
$27.00
|
| Rate for Payer: Networks By Design Commercial |
$23.40
|
| Rate for Payer: Prime Health Services Commercial |
$30.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$13.51
|
| Rate for Payer: United Healthcare All Other HMO |
$13.15
|
| Rate for Payer: United Healthcare HMO Rider |
$12.87
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$11.79
|
|
|
KIT PREPARATION OF TC 99M-SESTAMIBI COMBO NO.1 IV SOLUTION [121547]
|
Facility
|
OP
|
$36.00
|
|
|
Service Code
|
HCPCS A9500
|
| Hospital Charge Code |
901700057
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$7.20 |
| Max. Negotiated Rate |
$184.98 |
| Rate for Payer: Adventist Health Commercial |
$7.20
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$30.60
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$19.80
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$27.00
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$17.43
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$21.14
|
| Rate for Payer: Blue Shield of California Commercial |
$21.85
|
| Rate for Payer: Blue Shield of California EPN |
$14.29
|
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Central Health Plan Commercial |
$28.80
|
| Rate for Payer: Cigna of CA HMO |
$23.04
|
| Rate for Payer: Cigna of CA PPO |
$26.64
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$30.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$30.60
|
| Rate for Payer: Dignity Health Medicare Advantage |
$30.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.40
|
| Rate for Payer: EPIC Health Plan Senior |
$14.40
|
| Rate for Payer: Galaxy Health WC |
$30.60
|
| Rate for Payer: Global Benefits Group Commercial |
$21.60
|
| Rate for Payer: Health Management Network EPO/PPO |
$32.40
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$167.46
|
| Rate for Payer: InnovAge PACE Commercial |
$18.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$24.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$184.98
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$22.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.20
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$25.20
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$25.20
|
| Rate for Payer: Multiplan Commercial |
$27.00
|
| Rate for Payer: Networks By Design Commercial |
$23.40
|
| Rate for Payer: Prime Health Services Commercial |
$30.60
|
| Rate for Payer: Riverside University Health System MISP |
$14.40
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$21.60
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$21.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$13.51
|
| Rate for Payer: United Healthcare All Other HMO |
$13.15
|
| Rate for Payer: United Healthcare HMO Rider |
$12.87
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$11.79
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$30.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$30.60
|
| Rate for Payer: Vantage Medical Group Senior |
$30.60
|
|
|
KIT PREPARATION OF TC-99M-SODIUM PYROPHOSPHATE 12 MG IV SOLUTION [121139]
|
Facility
|
IP
|
$28.62
|
|
|
Service Code
|
HCPCS A9538
|
| Hospital Charge Code |
901700057
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$5.72 |
| Max. Negotiated Rate |
$25.76 |
| Rate for Payer: Adventist Health Commercial |
$5.72
|
| Rate for Payer: Blue Shield of California Commercial |
$22.12
|
| Rate for Payer: Blue Shield of California EPN |
$14.42
|
| Rate for Payer: Cash Price |
$15.74
|
| Rate for Payer: Central Health Plan Commercial |
$22.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.45
|
| Rate for Payer: EPIC Health Plan Senior |
$11.45
|
| Rate for Payer: Galaxy Health WC |
$24.33
|
| Rate for Payer: Global Benefits Group Commercial |
$17.17
|
| Rate for Payer: Health Management Network EPO/PPO |
$25.76
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$19.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.90
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$17.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.72
|
| Rate for Payer: Multiplan Commercial |
$21.46
|
| Rate for Payer: Networks By Design Commercial |
$18.60
|
| Rate for Payer: Prime Health Services Commercial |
$24.33
|
| Rate for Payer: United Healthcare All Other Commercial |
$10.74
|
| Rate for Payer: United Healthcare All Other HMO |
$10.45
|
| Rate for Payer: United Healthcare HMO Rider |
$10.23
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$9.37
|
|
|
KIT PREPARATION OF TC-99M-SODIUM PYROPHOSPHATE 12 MG IV SOLUTION [121139]
|
Facility
|
OP
|
$28.62
|
|
|
Service Code
|
HCPCS A9538
|
| Hospital Charge Code |
901700057
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$5.72 |
| Max. Negotiated Rate |
$121.69 |
| Rate for Payer: Adventist Health Commercial |
$5.72
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$24.33
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$15.74
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$21.46
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$13.86
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$16.81
|
| Rate for Payer: Blue Shield of California Commercial |
$17.37
|
| Rate for Payer: Blue Shield of California EPN |
$11.36
|
| Rate for Payer: Cash Price |
$15.74
|
| Rate for Payer: Cash Price |
$15.74
|
| Rate for Payer: Central Health Plan Commercial |
$22.90
|
| Rate for Payer: Cigna of CA HMO |
$18.32
|
| Rate for Payer: Cigna of CA PPO |
$21.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$24.33
|
| Rate for Payer: Dignity Health Medi-Cal |
$24.33
|
| Rate for Payer: Dignity Health Medicare Advantage |
$24.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.45
|
| Rate for Payer: EPIC Health Plan Senior |
$11.45
|
| Rate for Payer: Galaxy Health WC |
$24.33
|
| Rate for Payer: Global Benefits Group Commercial |
$17.17
|
| Rate for Payer: Health Management Network EPO/PPO |
$25.76
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$110.17
|
| Rate for Payer: InnovAge PACE Commercial |
$14.31
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$19.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$121.69
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$17.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.72
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$20.03
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$20.03
|
| Rate for Payer: Multiplan Commercial |
$21.46
|
| Rate for Payer: Networks By Design Commercial |
$18.60
|
| Rate for Payer: Prime Health Services Commercial |
$24.33
|
| Rate for Payer: Riverside University Health System MISP |
$11.45
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$17.17
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$17.17
|
| Rate for Payer: United Healthcare All Other Commercial |
$10.74
|
| Rate for Payer: United Healthcare All Other HMO |
$10.45
|
| Rate for Payer: United Healthcare HMO Rider |
$10.23
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$9.37
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$24.33
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$24.33
|
| Rate for Payer: Vantage Medical Group Senior |
$24.33
|
|
|
K-PHOS NEUTRAL ORAL SUSP CMPD 25 MG/ML (0.1 MEQ/ML) [4080284]
|
Facility
|
OP
|
$0.49
|
|
|
Service Code
|
NDC 9994-0802-84
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.44 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.30
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.42
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.27
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.37
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.24
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.29
|
| Rate for Payer: Blue Shield of California Commercial |
$0.30
|
| Rate for Payer: Blue Shield of California EPN |
$0.20
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Central Health Plan Commercial |
$0.39
|
| Rate for Payer: Cigna of CA HMO |
$0.34
|
| Rate for Payer: Cigna of CA PPO |
$0.34
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.42
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.42
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.20
|
| Rate for Payer: EPIC Health Plan Senior |
$0.20
|
| Rate for Payer: Galaxy Health WC |
$0.42
|
| Rate for Payer: Global Benefits Group Commercial |
$0.29
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.44
|
| Rate for Payer: InnovAge PACE Commercial |
$0.25
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.34
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.34
|
| Rate for Payer: Multiplan Commercial |
$0.37
|
| Rate for Payer: Networks By Design Commercial |
$0.32
|
| Rate for Payer: Prime Health Services Commercial |
$0.42
|
| Rate for Payer: Riverside University Health System MISP |
$0.20
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.29
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.29
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.25
|
| Rate for Payer: United Healthcare All Other HMO |
$0.25
|
| Rate for Payer: United Healthcare HMO Rider |
$0.25
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.25
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.42
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.42
|
| Rate for Payer: Vantage Medical Group Senior |
$0.42
|
|
|
K-PHOS NEUTRAL ORAL SUSP CMPD 25 MG/ML (0.1 MEQ/ML) [4080284]
|
Facility
|
IP
|
$0.49
|
|
|
Service Code
|
NDC 9994-0802-84
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.44 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Blue Shield of California Commercial |
$0.38
|
| Rate for Payer: Blue Shield of California EPN |
$0.25
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Central Health Plan Commercial |
$0.39
|
| Rate for Payer: Cigna of CA HMO |
$0.34
|
| Rate for Payer: Cigna of CA PPO |
$0.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.20
|
| Rate for Payer: EPIC Health Plan Senior |
$0.20
|
| Rate for Payer: Galaxy Health WC |
$0.42
|
| Rate for Payer: Global Benefits Group Commercial |
$0.29
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.37
|
| Rate for Payer: Networks By Design Commercial |
$0.32
|
| Rate for Payer: Prime Health Services Commercial |
$0.42
|
|
|
LABETALOL 100 MG TABLET [10373]
|
Facility
|
OP
|
$0.54
|
|
|
Service Code
|
NDC 60687-439-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.49 |
| Rate for Payer: Adventist Health Commercial |
$0.11
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.33
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.46
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.30
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.41
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.26
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.32
|
| Rate for Payer: Blue Shield of California Commercial |
$0.33
|
| Rate for Payer: Blue Shield of California EPN |
$0.22
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Central Health Plan Commercial |
$0.43
|
| Rate for Payer: Cigna of CA HMO |
$0.38
|
| Rate for Payer: Cigna of CA PPO |
$0.38
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.46
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.46
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.22
|
| Rate for Payer: EPIC Health Plan Senior |
$0.22
|
| Rate for Payer: Galaxy Health WC |
$0.46
|
| Rate for Payer: Global Benefits Group Commercial |
$0.32
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.49
|
| Rate for Payer: InnovAge PACE Commercial |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.21
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.38
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.38
|
| Rate for Payer: Multiplan Commercial |
$0.41
|
| Rate for Payer: Networks By Design Commercial |
$0.35
|
| Rate for Payer: Prime Health Services Commercial |
$0.46
|
| Rate for Payer: Riverside University Health System MISP |
$0.22
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.32
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.32
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.27
|
| Rate for Payer: United Healthcare All Other HMO |
$0.27
|
| Rate for Payer: United Healthcare HMO Rider |
$0.27
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.27
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.46
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.46
|
| Rate for Payer: Vantage Medical Group Senior |
$0.46
|
|
|
LABETALOL 100 MG TABLET [10373]
|
Facility
|
IP
|
$0.49
|
|
|
Service Code
|
NDC 68001-381-00
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.44 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Blue Shield of California Commercial |
$0.38
|
| Rate for Payer: Blue Shield of California EPN |
$0.25
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Central Health Plan Commercial |
$0.39
|
| Rate for Payer: Cigna of CA HMO |
$0.34
|
| Rate for Payer: Cigna of CA PPO |
$0.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.20
|
| Rate for Payer: EPIC Health Plan Senior |
$0.20
|
| Rate for Payer: Galaxy Health WC |
$0.42
|
| Rate for Payer: Global Benefits Group Commercial |
$0.29
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.37
|
| Rate for Payer: Networks By Design Commercial |
$0.32
|
| Rate for Payer: Prime Health Services Commercial |
$0.42
|
|
|
LABETALOL 100 MG TABLET [10373]
|
Facility
|
OP
|
$0.54
|
|
|
Service Code
|
NDC 60687-439-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.49 |
| Rate for Payer: Adventist Health Commercial |
$0.11
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.33
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.46
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.30
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.41
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.26
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.32
|
| Rate for Payer: Blue Shield of California Commercial |
$0.33
|
| Rate for Payer: Blue Shield of California EPN |
$0.22
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Central Health Plan Commercial |
$0.43
|
| Rate for Payer: Cigna of CA HMO |
$0.38
|
| Rate for Payer: Cigna of CA PPO |
$0.38
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.46
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.46
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.22
|
| Rate for Payer: EPIC Health Plan Senior |
$0.22
|
| Rate for Payer: Galaxy Health WC |
$0.46
|
| Rate for Payer: Global Benefits Group Commercial |
$0.32
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.49
|
| Rate for Payer: InnovAge PACE Commercial |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.21
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.38
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.38
|
| Rate for Payer: Multiplan Commercial |
$0.41
|
| Rate for Payer: Networks By Design Commercial |
$0.35
|
| Rate for Payer: Prime Health Services Commercial |
$0.46
|
| Rate for Payer: Riverside University Health System MISP |
$0.22
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.32
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.32
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.27
|
| Rate for Payer: United Healthcare All Other HMO |
$0.27
|
| Rate for Payer: United Healthcare HMO Rider |
$0.27
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.27
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.46
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.46
|
| Rate for Payer: Vantage Medical Group Senior |
$0.46
|
|
|
LABETALOL 100 MG TABLET [10373]
|
Facility
|
OP
|
$0.49
|
|
|
Service Code
|
NDC 68001-381-00
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.44 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.30
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.42
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.27
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.37
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.24
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.29
|
| Rate for Payer: Blue Shield of California Commercial |
$0.30
|
| Rate for Payer: Blue Shield of California EPN |
$0.20
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Central Health Plan Commercial |
$0.39
|
| Rate for Payer: Cigna of CA HMO |
$0.34
|
| Rate for Payer: Cigna of CA PPO |
$0.34
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.42
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.42
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.20
|
| Rate for Payer: EPIC Health Plan Senior |
$0.20
|
| Rate for Payer: Galaxy Health WC |
$0.42
|
| Rate for Payer: Global Benefits Group Commercial |
$0.29
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.44
|
| Rate for Payer: InnovAge PACE Commercial |
$0.25
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.34
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.34
|
| Rate for Payer: Multiplan Commercial |
$0.37
|
| Rate for Payer: Networks By Design Commercial |
$0.32
|
| Rate for Payer: Prime Health Services Commercial |
$0.42
|
| Rate for Payer: Riverside University Health System MISP |
$0.20
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.29
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.29
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.25
|
| Rate for Payer: United Healthcare All Other HMO |
$0.25
|
| Rate for Payer: United Healthcare HMO Rider |
$0.25
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.25
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.42
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.42
|
| Rate for Payer: Vantage Medical Group Senior |
$0.42
|
|
|
LABETALOL 100 MG TABLET [10373]
|
Facility
|
IP
|
$0.54
|
|
|
Service Code
|
NDC 60687-439-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.49 |
| Rate for Payer: Adventist Health Commercial |
$0.11
|
| Rate for Payer: Blue Shield of California Commercial |
$0.42
|
| Rate for Payer: Blue Shield of California EPN |
$0.27
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Central Health Plan Commercial |
$0.43
|
| Rate for Payer: Cigna of CA HMO |
$0.38
|
| Rate for Payer: Cigna of CA PPO |
$0.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.22
|
| Rate for Payer: EPIC Health Plan Senior |
$0.22
|
| Rate for Payer: Galaxy Health WC |
$0.46
|
| Rate for Payer: Global Benefits Group Commercial |
$0.32
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.49
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.21
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.41
|
| Rate for Payer: Networks By Design Commercial |
$0.35
|
| Rate for Payer: Prime Health Services Commercial |
$0.46
|
|
|
LABETALOL 100 MG TABLET [10373]
|
Facility
|
IP
|
$0.54
|
|
|
Service Code
|
NDC 60687-439-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.49 |
| Rate for Payer: Adventist Health Commercial |
$0.11
|
| Rate for Payer: Blue Shield of California Commercial |
$0.42
|
| Rate for Payer: Blue Shield of California EPN |
$0.27
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Central Health Plan Commercial |
$0.43
|
| Rate for Payer: Cigna of CA HMO |
$0.38
|
| Rate for Payer: Cigna of CA PPO |
$0.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.22
|
| Rate for Payer: EPIC Health Plan Senior |
$0.22
|
| Rate for Payer: Galaxy Health WC |
$0.46
|
| Rate for Payer: Global Benefits Group Commercial |
$0.32
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.49
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.21
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.41
|
| Rate for Payer: Networks By Design Commercial |
$0.35
|
| Rate for Payer: Prime Health Services Commercial |
$0.46
|
|
|
LABETALOL 200 MG TABLET [10374]
|
Facility
|
OP
|
$0.68
|
|
|
Service Code
|
NDC 68001-382-00
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.61 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.41
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.58
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.37
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.51
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.33
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.40
|
| Rate for Payer: Blue Shield of California Commercial |
$0.42
|
| Rate for Payer: Blue Shield of California EPN |
$0.27
|
| Rate for Payer: Cash Price |
$0.37
|
| Rate for Payer: Central Health Plan Commercial |
$0.54
|
| Rate for Payer: Cigna of CA HMO |
$0.48
|
| Rate for Payer: Cigna of CA PPO |
$0.48
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.58
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.58
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.27
|
| Rate for Payer: EPIC Health Plan Senior |
$0.27
|
| Rate for Payer: Galaxy Health WC |
$0.58
|
| Rate for Payer: Global Benefits Group Commercial |
$0.41
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.61
|
| Rate for Payer: InnovAge PACE Commercial |
$0.34
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.48
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.48
|
| Rate for Payer: Multiplan Commercial |
$0.51
|
| Rate for Payer: Networks By Design Commercial |
$0.44
|
| Rate for Payer: Prime Health Services Commercial |
$0.58
|
| Rate for Payer: Riverside University Health System MISP |
$0.27
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.41
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.41
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.34
|
| Rate for Payer: United Healthcare All Other HMO |
$0.34
|
| Rate for Payer: United Healthcare HMO Rider |
$0.34
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.34
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.58
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.58
|
| Rate for Payer: Vantage Medical Group Senior |
$0.58
|
|
|
LABETALOL 200 MG TABLET [10374]
|
Facility
|
OP
|
$0.34
|
|
|
Service Code
|
NDC 70377-061-12
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.31 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.21
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.29
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.19
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.26
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.16
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.20
|
| Rate for Payer: Blue Shield of California Commercial |
$0.21
|
| Rate for Payer: Blue Shield of California EPN |
$0.14
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Central Health Plan Commercial |
$0.27
|
| Rate for Payer: Cigna of CA HMO |
$0.24
|
| Rate for Payer: Cigna of CA PPO |
$0.24
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.29
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.29
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: EPIC Health Plan Senior |
$0.14
|
| Rate for Payer: Galaxy Health WC |
$0.29
|
| Rate for Payer: Global Benefits Group Commercial |
$0.20
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.31
|
| Rate for Payer: InnovAge PACE Commercial |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.24
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.24
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
| Rate for Payer: Networks By Design Commercial |
$0.22
|
| Rate for Payer: Prime Health Services Commercial |
$0.29
|
| Rate for Payer: Riverside University Health System MISP |
$0.14
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.20
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.20
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.17
|
| Rate for Payer: United Healthcare All Other HMO |
$0.17
|
| Rate for Payer: United Healthcare HMO Rider |
$0.17
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.17
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.29
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.29
|
| Rate for Payer: Vantage Medical Group Senior |
$0.29
|
|
|
LABETALOL 200 MG TABLET [10374]
|
Facility
|
IP
|
$0.34
|
|
|
Service Code
|
NDC 70377-061-12
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.31 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Blue Shield of California Commercial |
$0.26
|
| Rate for Payer: Blue Shield of California EPN |
$0.17
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Central Health Plan Commercial |
$0.27
|
| Rate for Payer: Cigna of CA HMO |
$0.24
|
| Rate for Payer: Cigna of CA PPO |
$0.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: EPIC Health Plan Senior |
$0.14
|
| Rate for Payer: Galaxy Health WC |
$0.29
|
| Rate for Payer: Global Benefits Group Commercial |
$0.20
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.31
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
| Rate for Payer: Networks By Design Commercial |
$0.22
|
| Rate for Payer: Prime Health Services Commercial |
$0.29
|
|
