|
1-stage distal hypospadias repair (with or without chordee or circumcision); with simple meatal advancement (eg, Magpi, V-flap)
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 54322
|
| Min. Negotiated Rate |
$1,052.39 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$3,728.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$6,533.58
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4,791.29
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4,355.72
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,547.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,533.58
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,791.29
|
| Rate for Payer: Dignity Health Senior |
$4,355.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$4,355.72
|
| Rate for Payer: Humana Medicare |
$4,355.72
|
| Rate for Payer: IEHP Medi-Cal |
$1,052.39
|
| Rate for Payer: IEHP Medicare Advantage |
$4,355.72
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$8,275.87
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5,139.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5,488.21
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5,488.21
|
| Rate for Payer: TriValley Medical Group Commercial |
$4,791.29
|
| Rate for Payer: TriValley Medical Group Senior |
$4,355.72
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,533.58
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,791.29
|
| Rate for Payer: Vantage Medical Group Senior |
$4,355.72
|
|
|
1-stage distal hypospadias repair (with or without chordee or circumcision); with urethroplasty by local skin flaps (eg, flip-flap, prepucial flap)
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 54324
|
| Min. Negotiated Rate |
$210.24 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$3,728.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$6,533.58
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4,791.29
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4,355.72
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,505.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,533.58
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,791.29
|
| Rate for Payer: Dignity Health Senior |
$4,355.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$4,355.72
|
| Rate for Payer: Humana Medicare |
$4,355.72
|
| Rate for Payer: IEHP Medi-Cal |
$210.24
|
| Rate for Payer: IEHP Medicare Advantage |
$4,355.72
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$8,275.87
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5,139.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5,488.21
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5,488.21
|
| Rate for Payer: TriValley Medical Group Commercial |
$4,791.29
|
| Rate for Payer: TriValley Medical Group Senior |
$4,355.72
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,533.58
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,791.29
|
| Rate for Payer: Vantage Medical Group Senior |
$4,355.72
|
|
|
1-stage proximal penile or penoscrotal hypospadias repair requiring extensive dissection to correct chordee and urethroplasty by use of skin graft tube and/or island flap
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 54332
|
| Min. Negotiated Rate |
$1,315.49 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$5,088.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$6,533.58
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4,791.29
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4,355.72
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7,436.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,533.58
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,791.29
|
| Rate for Payer: Dignity Health Senior |
$4,355.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$4,355.72
|
| Rate for Payer: Humana Medicare |
$4,355.72
|
| Rate for Payer: IEHP Medi-Cal |
$1,315.49
|
| Rate for Payer: IEHP Medicare Advantage |
$4,355.72
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$8,275.87
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5,139.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5,488.21
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5,488.21
|
| Rate for Payer: TriValley Medical Group Commercial |
$4,791.29
|
| Rate for Payer: TriValley Medical Group Senior |
$4,355.72
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,533.58
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,791.29
|
| Rate for Payer: Vantage Medical Group Senior |
$4,355.72
|
|
|
ABACAVIR 20 MG/ML ORAL SOLUTION [24439]
|
Facility
IP
|
$0.63
|
|
|
Service Code
|
NDC 31722-562-24
|
| Hospital Charge Code |
NDG24439
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.47 |
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.43
|
| Rate for Payer: Cash Price |
$0.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.34
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.43
|
| Rate for Payer: Heritage Provider Network Senior |
$0.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$0.47
|
|
|
ABACAVIR 20 MG/ML ORAL SOLUTION [24439]
|
Facility
OP
|
$0.63
|
|
|
Service Code
|
NDC 31722-562-24
|
| Hospital Charge Code |
NDG24439
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.54 |
| Rate for Payer: Adventist Health Commercial |
$0.13
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.34
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.43
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.54
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.35
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.47
|
| Rate for Payer: Blue Shield of California Commercial |
$0.39
|
| Rate for Payer: Blue Shield of California EPN |
$0.37
|
| Rate for Payer: Cash Price |
$0.28
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.41
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.54
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.54
|
| Rate for Payer: Dignity Health Senior |
$0.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.39
|
| Rate for Payer: Heritage Provider Network Senior |
$0.39
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$0.47
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.54
|
| Rate for Payer: Vantage Medical Group Senior |
$0.54
|
|
|
ABACAVIR 300 MG TABLET [24438]
|
Facility
OP
|
$10.59
|
|
|
Service Code
|
NDC 68084-021-11
|
| Hospital Charge Code |
1710876
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.92 |
| Max. Negotiated Rate |
$9.00 |
| Rate for Payer: Adventist Health Commercial |
$2.12
|
| Rate for Payer: Aetna of CA Gatekeeper |
$5.66
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.28
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$9.00
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$5.82
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$7.94
|
| Rate for Payer: Blue Shield of California Commercial |
$6.58
|
| Rate for Payer: Blue Shield of California EPN |
$6.22
|
| Rate for Payer: Cash Price |
$4.77
|
| Rate for Payer: Cigna of CA HMO/PPO |
$6.88
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.00
|
| Rate for Payer: Dignity Health Senior |
$9.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.78
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.56
|
| Rate for Payer: Heritage Provider Network Senior |
$6.56
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.65
|
| Rate for Payer: Multiplan Commercial |
$7.94
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.00
|
| Rate for Payer: Vantage Medical Group Senior |
$9.00
|
|
|
ABACAVIR 300 MG TABLET [24438]
|
Facility
IP
|
$3.00
|
|
|
Service Code
|
NDC 31722-557-60
|
| Hospital Charge Code |
1710876
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.54 |
| Max. Negotiated Rate |
$2.25 |
| Rate for Payer: Adventist Health Commercial |
$0.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.06
|
| Rate for Payer: Cash Price |
$1.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.62
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.03
|
| Rate for Payer: Heritage Provider Network Senior |
$2.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.75
|
| Rate for Payer: Multiplan Commercial |
$2.25
|
|
|
ABACAVIR 300 MG TABLET [24438]
|
Facility
OP
|
$3.00
|
|
|
Service Code
|
NDC 31722-557-60
|
| Hospital Charge Code |
1710876
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.54 |
| Max. Negotiated Rate |
$2.55 |
| Rate for Payer: Adventist Health Commercial |
$0.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.06
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.55
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.65
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.25
|
| Rate for Payer: Blue Shield of California Commercial |
$1.86
|
| Rate for Payer: Blue Shield of California EPN |
$1.76
|
| Rate for Payer: Cash Price |
$1.35
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.95
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.55
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.55
|
| Rate for Payer: Dignity Health Senior |
$2.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.92
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.86
|
| Rate for Payer: Heritage Provider Network Senior |
$1.86
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.75
|
| Rate for Payer: Multiplan Commercial |
$2.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.55
|
| Rate for Payer: Vantage Medical Group Senior |
$2.55
|
|
|
ABACAVIR 300 MG TABLET [24438]
|
Facility
IP
|
$10.59
|
|
|
Service Code
|
NDC 68084-021-11
|
| Hospital Charge Code |
1710876
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.92 |
| Max. Negotiated Rate |
$7.94 |
| Rate for Payer: Adventist Health Commercial |
$2.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.28
|
| Rate for Payer: Cash Price |
$4.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.72
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.17
|
| Rate for Payer: Heritage Provider Network Senior |
$7.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.65
|
| Rate for Payer: Multiplan Commercial |
$7.94
|
|
|
ABACAVIR 600 MG-DOLUTEGRAVIR 50 MG-LAMIVUDINE 300 MG TABLET [207101]
|
Facility
OP
|
$141.50
|
|
|
Service Code
|
NDC 49702-231-13
|
| Hospital Charge Code |
ERX207101
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$25.61 |
| Max. Negotiated Rate |
$120.28 |
| Rate for Payer: Adventist Health Commercial |
$28.30
|
| Rate for Payer: Aetna of CA Gatekeeper |
$75.63
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$97.21
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$120.28
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$77.82
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$106.12
|
| Rate for Payer: Blue Shield of California Commercial |
$87.87
|
| Rate for Payer: Blue Shield of California EPN |
$83.06
|
| Rate for Payer: Cash Price |
$63.68
|
| Rate for Payer: Cigna of CA HMO/PPO |
$91.98
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$120.28
|
| Rate for Payer: Dignity Health Medi-Cal |
$120.28
|
| Rate for Payer: Dignity Health Senior |
$120.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$90.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$87.59
|
| Rate for Payer: Heritage Provider Network Senior |
$87.59
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$68.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$25.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$35.38
|
| Rate for Payer: Multiplan Commercial |
$106.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$120.28
|
| Rate for Payer: Vantage Medical Group Senior |
$120.28
|
|
|
ABACAVIR 600 MG-DOLUTEGRAVIR 50 MG-LAMIVUDINE 300 MG TABLET [207101]
|
Facility
IP
|
$141.50
|
|
|
Service Code
|
NDC 49702-231-13
|
| Hospital Charge Code |
ERX207101
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$25.61 |
| Max. Negotiated Rate |
$106.12 |
| Rate for Payer: Adventist Health Commercial |
$28.30
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$97.21
|
| Rate for Payer: Cash Price |
$63.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$76.41
|
| Rate for Payer: Heritage Provider Network Commercial |
$95.80
|
| Rate for Payer: Heritage Provider Network Senior |
$95.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$25.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$35.38
|
| Rate for Payer: Multiplan Commercial |
$106.12
|
|
|
ABACAVIR 600 MG-LAMIVUDINE 300 MG TABLET [39301]
|
Facility
OP
|
$4.00
|
|
|
Service Code
|
NDC 69097-362-02
|
| Hospital Charge Code |
1711932
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.72 |
| Max. Negotiated Rate |
$3.40 |
| Rate for Payer: Adventist Health Commercial |
$0.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.75
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3.40
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.20
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3.00
|
| Rate for Payer: Blue Shield of California Commercial |
$2.48
|
| Rate for Payer: Blue Shield of California EPN |
$2.35
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.40
|
| Rate for Payer: Dignity Health Senior |
$3.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.48
|
| Rate for Payer: Heritage Provider Network Senior |
$2.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.93
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.00
|
| Rate for Payer: Multiplan Commercial |
$3.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.40
|
| Rate for Payer: Vantage Medical Group Senior |
$3.40
|
|
|
ABACAVIR 600 MG-LAMIVUDINE 300 MG TABLET [39301]
|
Facility
IP
|
$4.00
|
|
|
Service Code
|
NDC 69097-362-02
|
| Hospital Charge Code |
1711932
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.72 |
| Max. Negotiated Rate |
$3.00 |
| Rate for Payer: Adventist Health Commercial |
$0.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.75
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.71
|
| Rate for Payer: Heritage Provider Network Senior |
$2.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.00
|
| Rate for Payer: Multiplan Commercial |
$3.00
|
|
|
ABATACEPT (WITH MALTOSE) 250 MG INTRAVENOUS SOLUTION [70287]
|
Facility
IP
|
$1,655.88
|
|
|
Service Code
|
CPT J0129
|
| Hospital Charge Code |
1720952
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$299.71 |
| Max. Negotiated Rate |
$1,241.91 |
| Rate for Payer: Adventist Health Commercial |
$331.18
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,137.59
|
| Rate for Payer: Cash Price |
$745.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$761.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$894.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,121.03
|
| Rate for Payer: Heritage Provider Network Senior |
$1,121.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$299.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$413.97
|
| Rate for Payer: Multiplan Commercial |
$1,241.91
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$603.73
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$553.23
|
|
|
ABATACEPT (WITH MALTOSE) 250 MG INTRAVENOUS SOLUTION [70287]
|
Facility
OP
|
$1,655.88
|
|
|
Service Code
|
CPT J0129
|
| Hospital Charge Code |
1720952
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$40.17 |
| Max. Negotiated Rate |
$1,241.91 |
| Rate for Payer: Adventist Health Commercial |
$331.18
|
| Rate for Payer: Aetna of CA Gatekeeper |
$85.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,137.59
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$53.95
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$47.48
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$47.48
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$40.17
|
| Rate for Payer: Blue Shield of California Commercial |
$53.13
|
| Rate for Payer: Blue Shield of California EPN |
$53.13
|
| Rate for Payer: Cash Price |
$745.15
|
| Rate for Payer: Cash Price |
$745.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$761.70
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$64.74
|
| Rate for Payer: Dignity Health Medi-Cal |
$47.48
|
| Rate for Payer: Dignity Health Senior |
$47.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,059.76
|
| Rate for Payer: EPIC Health Plan Medicare |
$43.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$766.67
|
| Rate for Payer: Heritage Provider Network Senior |
$766.67
|
| Rate for Payer: Humana Medicare |
$43.16
|
| Rate for Payer: IEHP Medi-Cal |
$74.29
|
| Rate for Payer: IEHP Medicare Advantage |
$43.16
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$82.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$299.71
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$50.93
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$413.97
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$54.39
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$54.39
|
| Rate for Payer: Multiplan Commercial |
$1,241.91
|
| Rate for Payer: TriValley Medical Group Commercial |
$47.48
|
| Rate for Payer: TriValley Medical Group Senior |
$43.16
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$603.73
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$553.23
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$64.74
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$47.48
|
| Rate for Payer: Vantage Medical Group Senior |
$43.16
|
|
|
ABDOMINAL PAIN
|
Facility
IP
|
$7,016.00
|
|
|
Service Code
|
APR-DRG 2513
|
| Min. Negotiated Rate |
$7,016.00 |
| Max. Negotiated Rate |
$7,016.00 |
| Rate for Payer: IEHP Medi-Cal |
$7,016.00
|
|
|
ABDOMINAL PAIN
|
Facility
IP
|
$5,314.73
|
|
|
Service Code
|
APR-DRG 2512
|
| Min. Negotiated Rate |
$5,314.73 |
| Max. Negotiated Rate |
$5,314.73 |
| Rate for Payer: IEHP Medi-Cal |
$5,314.73
|
|
|
ABDOMINAL PAIN
|
Facility
IP
|
$11,857.17
|
|
|
Service Code
|
APR-DRG 2514
|
| Min. Negotiated Rate |
$11,857.17 |
| Max. Negotiated Rate |
$11,857.17 |
| Rate for Payer: IEHP Medi-Cal |
$11,857.17
|
|
|
ABDOMINAL PAIN
|
Facility
IP
|
$4,114.89
|
|
|
Service Code
|
APR-DRG 2511
|
| Min. Negotiated Rate |
$4,114.89 |
| Max. Negotiated Rate |
$4,114.89 |
| Rate for Payer: IEHP Medi-Cal |
$4,114.89
|
|
|
ABEMACICLIB 100 MG TABLET [219901]
|
Facility
IP
|
$311.44
|
|
|
Service Code
|
NDC 0002-4815-54
|
| Hospital Charge Code |
ERX219901
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$56.37 |
| Max. Negotiated Rate |
$233.58 |
| Rate for Payer: Adventist Health Commercial |
$62.29
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$213.96
|
| Rate for Payer: Cash Price |
$140.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$168.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$210.84
|
| Rate for Payer: Heritage Provider Network Senior |
$210.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$56.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$77.86
|
| Rate for Payer: Multiplan Commercial |
$233.58
|
|
|
ABEMACICLIB 100 MG TABLET [219901]
|
Facility
OP
|
$311.44
|
|
|
Service Code
|
NDC 0002-4815-54
|
| Hospital Charge Code |
ERX219901
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$56.37 |
| Max. Negotiated Rate |
$264.72 |
| Rate for Payer: Adventist Health Commercial |
$62.29
|
| Rate for Payer: Aetna of CA Gatekeeper |
$166.46
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$213.96
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$264.72
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$171.29
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$233.58
|
| Rate for Payer: Blue Shield of California Commercial |
$193.40
|
| Rate for Payer: Blue Shield of California EPN |
$182.82
|
| Rate for Payer: Cash Price |
$140.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$202.44
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$264.72
|
| Rate for Payer: Dignity Health Medi-Cal |
$264.72
|
| Rate for Payer: Dignity Health Senior |
$264.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$199.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$192.78
|
| Rate for Payer: Heritage Provider Network Senior |
$192.78
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$150.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$56.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$77.86
|
| Rate for Payer: Multiplan Commercial |
$233.58
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$264.72
|
| Rate for Payer: Vantage Medical Group Senior |
$264.72
|
|
|
ABEMACICLIB 150 MG TABLET [219900]
|
Facility
IP
|
$311.44
|
|
|
Service Code
|
NDC 0002-5337-54
|
| Hospital Charge Code |
ERX219900
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$56.37 |
| Max. Negotiated Rate |
$233.58 |
| Rate for Payer: Adventist Health Commercial |
$62.29
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$213.96
|
| Rate for Payer: Cash Price |
$140.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$168.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$210.84
|
| Rate for Payer: Heritage Provider Network Senior |
$210.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$56.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$77.86
|
| Rate for Payer: Multiplan Commercial |
$233.58
|
|
|
ABEMACICLIB 150 MG TABLET [219900]
|
Facility
OP
|
$311.44
|
|
|
Service Code
|
NDC 0002-5337-54
|
| Hospital Charge Code |
ERX219900
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$56.37 |
| Max. Negotiated Rate |
$264.72 |
| Rate for Payer: Adventist Health Commercial |
$62.29
|
| Rate for Payer: Aetna of CA Gatekeeper |
$166.46
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$213.96
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$264.72
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$171.29
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$233.58
|
| Rate for Payer: Blue Shield of California Commercial |
$193.40
|
| Rate for Payer: Blue Shield of California EPN |
$182.82
|
| Rate for Payer: Cash Price |
$140.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$202.44
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$264.72
|
| Rate for Payer: Dignity Health Medi-Cal |
$264.72
|
| Rate for Payer: Dignity Health Senior |
$264.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$199.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$192.78
|
| Rate for Payer: Heritage Provider Network Senior |
$192.78
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$150.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$56.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$77.86
|
| Rate for Payer: Multiplan Commercial |
$233.58
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$264.72
|
| Rate for Payer: Vantage Medical Group Senior |
$264.72
|
|
|
ABEMACICLIB 200 MG TABLET [219899]
|
Facility
OP
|
$311.44
|
|
|
Service Code
|
NDC 0002-6216-54
|
| Hospital Charge Code |
ERX219899
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$56.37 |
| Max. Negotiated Rate |
$264.72 |
| Rate for Payer: Adventist Health Commercial |
$62.29
|
| Rate for Payer: Aetna of CA Gatekeeper |
$166.46
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$213.96
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$264.72
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$171.29
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$233.58
|
| Rate for Payer: Blue Shield of California Commercial |
$193.40
|
| Rate for Payer: Blue Shield of California EPN |
$182.82
|
| Rate for Payer: Cash Price |
$140.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$202.44
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$264.72
|
| Rate for Payer: Dignity Health Medi-Cal |
$264.72
|
| Rate for Payer: Dignity Health Senior |
$264.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$199.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$192.78
|
| Rate for Payer: Heritage Provider Network Senior |
$192.78
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$150.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$56.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$77.86
|
| Rate for Payer: Multiplan Commercial |
$233.58
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$264.72
|
| Rate for Payer: Vantage Medical Group Senior |
$264.72
|
|
|
ABEMACICLIB 200 MG TABLET [219899]
|
Facility
IP
|
$311.44
|
|
|
Service Code
|
NDC 0002-6216-54
|
| Hospital Charge Code |
ERX219899
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$56.37 |
| Max. Negotiated Rate |
$233.58 |
| Rate for Payer: Adventist Health Commercial |
$62.29
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$213.96
|
| Rate for Payer: Cash Price |
$140.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$168.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$210.84
|
| Rate for Payer: Heritage Provider Network Senior |
$210.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$56.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$77.86
|
| Rate for Payer: Multiplan Commercial |
$233.58
|
|
